UC-NRLF 


B   M   330  033 


in 


Psychotherapeutics 


BY 

FREDERIC  H.  GERRISH 

JAMES  J.  PUTNAM, 

E.  W.  TAYLOR 

BORIS  SIDIS 

GEORGE  A.  WATERMAN 

JOHN  E.  DONLEY 

ERNEST  JONES 
TOM  A.  WILLIAMS 

AND 

MORTON  PRINCE 


RICHARD  G.  BADGER 

^de  (Soriiam  Ij^xtiii 

BOSTON 


/XZ4 

CopyHght,  1909  and  1912  by  Richard  O.  Badg$r  ^  ^ 


AU  Biyhtt  Regervtd  ?}S^^^^ 


Th$  Gorham  Preu,  Boston,  U.  8.  A, 


CONTENTS 

Chapter  Page 

Introduction 7 

I.     The    Psychological   Principles    and    Field    of 

Psychotherapy 9. 

Complex  Formation 18 

Conservation 18 

»                 Dissociation 9.% 

Automatism 26 

Emotional  Energy 27 

The  Relative  Advantages  of  Education  in 

Hypnosis  and  in  the  Waking  State     .  32 

Hysteria S7 

Psychasthenia  and  Obsessions  .      .      .      .  40 

II.     The  Therapeutic  Value  of  Hypnotic  Sugges- 

gestion 42 

Methods  of  Inducing  Hypnosis     ...  45 
Conditions  vh  which  Hypnotic  Suggestion 

is  Valuable 60 

Correction  of  Misconceptions   concerning 

Hypnotism 67 

III.  Simple  Explanation   and  Re-education  as  a 

Therapeutic   Method 68 

IV.  The  Treatment  of  Fatigue  States     ...  78 

Physiological  Fatigue   ......  78 

Psychological  Fatigue 80 

Psychopathological  Fatigue     ....  81 

V.     Psycho-Analysis   in  Psychotherapy    ...  98 

VI.     The   Psychotherapeutic   Value   of  the   Hyp- 

noidal  State 106 


C  i^fkfroo 


CONTENTS 

Chapter  Page 

VII.     Obsessions  and  Associated  Conditions  in  So- 

Called  Psychasthenia 131 

VIII.     Psychoprophylaxis  in  Childhood  .      .      .      ,    141 

IX.     The    Relation    of    Character   Formation    to 

Psychotherapy     .      .      .      .      .      .      .    166 


INTRODUCTION 

THE  purpose  of  this  volume  is  to  present  a  brief,  in- 
telligible statement  of  the  methods  of  treatment 
by  psychic  means,  which  are  approved  by  scientific 
physicians,  and,  also,  a  description  of  the  classes  of  cases,  to 
which  such  methods  are  appropriately  applicable. 

The  book  owes  its  composite  character  to  circumstances, 
a  knowledge  of  which  will  give  added  interest  to  its  perusal; 
and  it  will  be  readily  perceived  that  the  value  of  the  work  is 
enhanced  by  the  fact  that  it  is  prepared  by  a  group  of 
specialists,  whose  combined  product  must  be  of  greater 
worth  than  that  of  any  one  writer,  however  able. 

In  1909,  one  of  the  authors.  Dr.  Gerrish,  was  president  of 
the  American  Therapeutic  Society,  and,  as  such,  had  the 
privilege  of  arranging  the  program  for  its  annual  meeting. 
A  careful  examination  of  the  programs  of  the  previous  years 
disclosed  the  fact  that,  although  this  national  association  is 
specifically  devoted,  as  its  name  implies,  to  the  treatment  of 
disease,  no  paper  on  psychic  remedies  had  ever  been  read 
before  it.  This  neglect  of  a  whole  class  of  curative  measures  is 
explicable  only  on  the  ground  of  the  lack  of  appreciation  of 
their  value  by  the  medical  profession  generally  —  a  lack 
attributable,  in  large  measure,  to  the  failure  of  medical 
schools  to  attempt  to  interest  their  students  in  these  agencies, 
and,  in  some  degree,  to  the  disrepute  into  which  psychic 
remedies  have  been  brought  by  their  dishonest  and  other- 
wise objectionable  exploitation  by  charlatans.  Certain  it  is 
that  the  profession  has  looked  askance  at  psychotherapy, 
and  has  been  unwilling  to  accord  it  the  respectful  hearing 
to  which  its  scientific  merits  entitle  it.  Dr.  Gerrish  con- 
sidered  the   annual   meeting   of    the  national  therapeutic 


INTRODUCTION 

society  a  peculiarly  opportune  occasion  for  the  presentation 
of  the  whole  subject,  and  conceived  the  project  of  a  sym- 
posium, in  which  the  different  aspects  of  psychotherapy 
would  be  treated,  each  by  a  physician,  whose  knowledge 
and  experience  qualified  him  to  speak  with  authority,  and 
whose  position  in  the  medical  profession  was  not  only  above 
reproach,  but  was  stamped  with  the  hallmark  of  dignity  and 
respect.  To  execute  this  design  he  invoked  the  interest  and 
invaluable  assistance  of  Dr.  Morton  Prince,  whose  fame  is 
world-wide;  and  by  the  personal  influence  of  this  master 
there  was  gathered  a  remarkable  coterie  of  experts  in  psycho- 
therapeutics. Dr.  Prince  opened  the  symposium  with  an 
essay  on  "The  Psychological  Principles  and  the  Need  of 
Psychotherapy";  and  was  followed  by  Dr.  Taylor  on  "Sim- 
ple Explanation  and  Re-education  as  a  Therapeutic  Method," 
Dr.  Jones  on  "Psycho-Analysis  in  Psychotherapy,"  Dr. 
Sidis  on  "The  Psychotherapeutic  Value  of  the  Hypnoidal 
State,"  Dr.  Waterman  on  "The  Treatment  of  Fatigue 
States,"  Dr.  Donley  on  "Obsessions  and  Associated  Con- 
ditions in  so-called  Psychasthenia,"  Dr.  Williams  on  "Psy- 
choprophylaxis  in  Childhood,"  and  Dr.  Putnam  on  "The 
Relation  of  Character-Formation  to  Psychotherapy."  Dr. 
Gerrish  took  "The  Therapeutic  Value  of  Hypnotic  Sugges- 
tion" as  the  subject  of  his  presidential  address. 

These  essays  were  received  with  marked  favor  on  the 
occasion  of  their  delivery,  were  soon  published  in  The  Journal 
of  Abnormal  Psychology,  and  then  appeared  in  book  form. 
The  fact  that  a  third  edition  of  the  volume  has  been  de- 
manded may  well  be  taken  as  an  evidence  that  it  has  won 
high  esteem  and  wide  appreciation.  Indeed,  it  has  been 
pronounced  by  persons  well  qualified  to  form  an  opinion 
in^the  premises  to  be  the  most  valuable,  as  well  as  the  most 
compact,  presentation  of  psychotherapy  that  has  ever  been 
made.  The  new  edition  is  issued  in  the  hope  that  the  book 
will  continue  to  enlighten  the  medical  profession  and  the 


INTRODUCTION 

public  on  a  subject  of  great  interest  and  practical  importance, 
and  aid  them  in  distinguishing  between  genuine,  scientific 
mind-cure  and  the  many  spurious  articles  that  masquerade 
under  various  alluring  and  deluding  names. 


PSYCHOTHERAPEUTICS 


i 


PSYCHOTHERAPEUTICS 


CHAPTER  ONE 

The  Psychological  Principles  and  Field  of  Psycho- 
therapy 
by  morton  prince,  m.  d. 

Professor  Emeritus  Tufts  College  Medical  School 

SO  much  that  is  pseudo-scientific  or  mere  platitude,  so 
many  misstatements  have  been  set  forth  in  the  lay 
and  medical  press  both  by  those  who  are  the  advo- 
cates of  psychotherapy  and  by  those  who  are  its  critics  i 
so  many  erroneous  ideas  abound  regarding  both  the  na- 
ture of  the  disturbances  of  the  mind  and  body  which  we 
seek  to  allay  and  the  modes  by  which  we  endeavor  to  do 
it,  that  it  is  not  to  be  wondered  at  that  the  facts  of  ob- 
servation have  been  mistrusted  and  the  methods  of  thera- 
peutics have  met  with  cynical  criticism. 

If  we  are  to  judge  the  soundness  of  the  theory  on 
which  this  mode  of  treatment  is  based,  the  field  of  its 
usefulness,  its  limitations,  and  the  methods  of  its  appli- 
cation, it  is  absolutely  necessary  that  we  should  begin 
any  discussion  of  psychotherapy,  in  a  symposium  of  this 
kind,  with  an  understanding  of  its  underlying  principles. 
There  are  certain  facts  of  observation  with  which  we 
may  begin. 

1.  It  will  be  agreed  that  common  experience  has 
shown  that  certain  unhealthy  habitual  states  of  mind  are 
apt  to  be  accompanied  by  various  derangements  of  the 
functions  of  the  body.  By  "  unhealthy  "  I  would  desig- 
nate those  which  tend  to  misadapt  a  person  to  his  en- 

9 


10  PSYCHOTHERAPEUTICS 

vironihent,  dnd  a'nfioug  these  habits  or  states  of  mind  I 
would    classify    depressive    or    disruptive    emotions    and 

\  feelings;  apprehensions,  and  fear  of  disease  or  of  the 
consequences  of  business  or  social  acts ;  fixed  beliefs  in 
fictitious  disease;  illogical  doubts,  scruples,  and  anxie- 

^  ties;  habits  of  thought  such  as  constant  introspection, 
self-consciousness,  the  concentration  of  the  attention  on 
the  physiological  functions  of  the  body,  the  expectation 
of  ill  consequences  following  any  course  of  conduct,  and 
so  on.  I  need  not  go  into  details,  for  that  such  condi- 
tions of  mind  are  accompanied  by  derangements  of  the 
bodily  functions  is  a  fact  of  common  knowledge  which 
is  confirmed  by  the  experience  of  laymen  as  well  as  phy- 
sicians and  psychologists.  Furthermore,  in  certain  per- 
sons the  modes  of  mental  activity  I  have  described  if 
X  frequently  repeated  tend  to  become  habits  or  habitual 
reactions  to  the  environment  that  are  not  easily  dis- 
carded. Often  the  mental  states  when  persistent  and 
intense  become  disabilities  in  themselves,  constituting 
veritable  psychoses,  such  as  the  anxiety  psychosis,  pho- 
bias of  various  kinds,  morbid  shyness  and  self-conscious- 
ness, association  psychoses,  etc.  It  is  not  to  be  affirmed 
that  these  unhealthy  mental  states  of  mind,  even  when 
they  become  habitual  phychoses,  are  accompanied  in 
every  individual  by  disturbance  of  bodily  functions,  but 
the  tendency  is  such  in  persons  of  a  certain  temperament 
and  so-called  nervous  organization. 

S.     It  is  also  a  fact  of  observation  which  is  too  well 
admitted   to   be  mistrusted   that,   when   healthy   mental 
states  are  substituted  for  unhealthy  ones  of  the  charac-, 
ter  I  have  described,  the  functional  derangements  of  the! 
body  tend  to  disappear. 

The  two  classes  of  facts  just  enumerated  become  com- 
prehensible when   we   remember   that   physiological   and 
clinical  observations  have  shown  that  temporary  or  pass-j 
ing  mental  states  when  accompanied  by  strong  feeling^ 


FIELD  OF  PSYCHOTHERAPY  11 

tones  often  alter  in  a  marked  degree  the  various  visceral 
functions.  To  mention  but  a  few  of  these  effects:  The 
increase  of  the  heart's  action;  the  increase  of  the  blood 
pressure;  the  variations  of  the  vasomotor  system;  the 
increased  muscular  energy  and  feeling  of  wellbeing; 
the  pouring  out  of  the  appetite  juice  and  saliva  (Paw- 
low),  etc.,  through  the  influence  of  ideas  associated  with 
sthenic  pleasurable  emotions  —  all  these  have  been  at- 
tested by  the  observations  of  the  physiologist  and  of 
the  clinician.  Per  contra,  the  suppression  of  salivary 
and  gastric  secretions ;  the  inhibition  of  peristalsis  and 
segmentation;  the  contraction  and  dilatation  of  the 
blood  vessels ;  the  increased  functions  of  the  sweat 
glands ;  the  alteration  in  the  rhythm  and  rapidity  of  the 
respiration  and  heart's  action ;  the  inhibition  of  many 
functions  (gastro-intestinal)  ;  the  decrease  of  muscular 
energy;  the  awakening  of  the  sense  and  symptoms  of 
fatigue;  these  and  many  such  phenomena  have  been 
shown  by  carefully  recorded  tests  to  accompany  the 
temporary  excitation  of  ideas  that  are  associated  with 
depressing  and  painful  emotions.  That  the  persistence 
of  such  mental  states  should  be  accompanied  by  per- 
sistent disturbance  of  function  is  not  to  be  wondered 
at. 

3.  A  third  class  of  facts  must,  I  think,  also  be  ac- 
cepted as  proven;  namely,  that  emotional  shocks  are  apt 
in  certain  persons  to  leave  persisting  after-effects  mani- 
fested by  disturbances  of  function  of  the  nervous  system. 
We  need  not  inquire  at  this  moment  into  the  exact  na- 
ture of  these  disturbances  or  give  them  a  name.  It  is 
generally  agreed  that  they  are  of  the  character  which 
is  called  functional  and  owe  their  evolution  to  the  prin- 
ciples which  I  will  presently  describe.  In  their  most  ob- 
trusive form  they  are  observed  as  the  traumatic  neuroses 
(psychoses). 

4.  A  fourth  class  of  facts  is  of  importance  for  psy- 


U  PSYCHOTHERAPEUTICS 

chotherapeutics,  viz.:  In  all  persons  to  a  certain  extent 
.  and  in  some  persons  to  a  large  extent  suggested  ideas 
tend  to  work  themselves  out  to  fulfilment.  In  certain 
diseased  states  (hysteria)  and  in  certain  artificial  states 
(hypnosis)  this  tendency  reaches  a  maximum  and,  con- 
sequently, by  suggestion,  intentionally  given  to  persons 
in  such  conditions,  disturbances  of  function  can  be  pro- 
duced artificially  and  removed  again.  Likewise  ideas 
V  originating  in  the  mind  of  the  person  himself  may  in- 
duce the  same  phenomena  (auto-suggestion).  Thus  on 
the  physiological  side  functional  paralysis,  contrac- 
tures, anesthesias,  spasms,  etc. ;  and  on  the  mental  side 
amnesias,  hallucinations,  sleep,  trains  of  ideas  and  feel- 
ing, etc.,  can  be  artificially  produced  and  afterwards 
modified  and  removed.  In  this  statement  I  am  not  in- 
cluding the  basic  condition,  whatever  it  may  be,  that 
\  gives  rise  to  the  increased  suggestibility,  but  to  the 
phenomena  resulting  from  suggestion.  How  far  that 
condition  comes  within  the  influence  of  suggestion  is  an- 
other question  to  which  I  will  later  return.  The  phe- 
nomena of  suggestion  have  been  determined  by  experi- 
ment over  and  over  again,  while  the  history  of  medicine 
testifies  to  the  occurrence  of  such  phenomena  under  acci- 
dental conditions.  Indeed  a  distinguished  neurologist 
(Babinski)  has  recently  advanced  the  thesis,  though  as 
I  believe  erroneously,  that  all  hysteria  is  nothing  but  a 
group  of  suggested  symptoms. 

We  cannot  be  too  cautious  in  generalizing  from  lim- 
ited facts  of  this  kind  which  are  observed  under  special 
conditions,  but  the  basic  principle  is  of  great  impor- 
tance and  one  that  obviously  can  be  made  use  of  in  psy- 
chotherapeutics. To  what  extent  it  can  be  used  is  an- 
other question  that  can  only  be  determined  by  experi- 
ence. 

After  this  general  statement  of  certain  fundamental 


FIELD  OF  PSYCHOTHERAPY  13 

facts  of  observation  I  would  call  attention  to  certain 
principles,  if  not  laws,  which  observation  has  shown  gov- 
ern the  functioning  of  the  nervous  system. 

1.       COMPLEX    FORMATION 

It  is  a  law  that  associated  ideas,  feelings,  emotions, 
sensations,  movements,  visceral  functions  of  whatever 
kind,  tend,  after  constant  repetition  or  when  accompa- 
nied by  strong  emotion  and  feeling  tones,  and  under 
other  conditions,  to  become  linked  together  into  a  sys- 
tem or  group  in  such  fashion  that  the  stimulation  of  one 
element  in  the  group  stimulates  the  activity  of  the  rest 
of  the  group.  Such  a  group  is  conveniently  called  a  v 
complex^  and  as  such  I  shall  hereafter  refer  to  it.  This 
tendency  to  linking  of  functions  obtains  whether  the 
mental  and  physiological  processes  when  linked  form  a 
complex  which  subserves  the  wellbeing  of  the '  organism 
and  adapts  the  individual  to  his  environment,  or  whether 
they  form  one  which  does  not  subserve  the  wellbeing  of 
the  individual,  but  misadapts  him  to  his  environment. 
In  the  former  case  the  complex  is  called  normal,  in  the 
latter  abnormal.  This  is  only  another  aspect  of  the 
well-accepted  principle  that  pathological  processes  are 
normal  processes  functioning  under  altered  conditions. 
Both  are  the  expression  of  one  and  the  same  melanism. 

The  linking  of  function  may  be  almost  entirely  of 
ideas,  as  is  expressed  by  the  well-known  psychological 
law  of  "  association  of  ideas."  Its  pathological  mani- 
festations we  see  in  so-called  fixed  ideas  or  obsessions.  "^ 
We  see  it  also  exemplified  within  normal  limits  in  so- 
called  moods,  when  certain  large  systems  of  ideas  accom- 
panied  by""  strong  emotion  tones  occupy  the  mental  field 
to  the  exclusion  of  other  systems  which  find  it  difficult 
to  take  possession  of  the  field  of  consciousness.  When 
such  moods  are  developed  and  intensified  to  an  extreme 


14  PSYCHOTHERAPEUTICS 

degree  we  have  veritable  pathological  alterations  of  per- 
sonality and  even,  it  may  be,  multiple  personality.  But 
in  moods  besides  association  we  meet  with  another  princi- 
ple in  an  exaggerated  form,  namely,  dissociation.  Of 
this  I  will  presently  speak. 

The  linking  again  may  be  of  physiological  processes 
as  ^exemplified  by  synergesis  of  muscular  movements. 
This  is  seen  in  the  linked  combination  of  muscles  used 
in  writing,  piano  pjaying,  skilled  use  of  tools,  and  imple- 
ments of  games  (golf,  tennis,  etc.).  Even  the  simpler 
movements  of  a  finger,  hand,  or  arm  require  the  coapt- 
ative  synergesis  of  several  muscles.  These  synergetic 
movements  are  admittedly  the  result  of  education 
through  repetition,  although  undoubtedly  the  compound 
cerebro-spinal  reflexes  so  beautifully  studied  and  brought 
to  light  by  Sherrington  are  made  use  of. 

The  possibility  of  organizing  physiological  processes 
into  memories  by  artificial  means  and  linking  them  to 
psychological  processes  is  shown  very  neatly  by  the  ex- 
tremely important  experiments  of  Pawlow  and  his  co- 
workers on  the  reflex  stimulation  of  saliva  in  dogs. 
The  facts  which  I  wish  here  to  recite  are  thus  described 
by  Pawlow: 

"  In  the  course  of  our  experiments  it  appeared  that  all 
the  phenomena  of  adaptation  which  we  saw  in  the 
salivary  glands  under  physiological  conditions,  such,  for 
instance,  as  the  introduction  of  the  stimulating  sub- 
stances into  the  buccal  cavity,  reappeared  in  exactly 
the  same  manner  under  the  influence  of  psychological 
conditions  —  that  is  to  say,  when  we  Inerely  drew  the 
animal's  attention  to  the  substances  in  question.  Thus, 
when  we  pretended  to  throw  pebbles  into  the  dog's 
mouth,  or  to  cast  in  sand,  or  to  pour  in  something  dis- 
agreeable, or,  finally,  when  we  off^ered  it  this  or  that  kind 
of  food,   a  secretion   either  immediately  appeared  or  it 


I 


FIELD  OF  PSYCHOTHERAP\  15 

did  not  appear,  in  accordance  with  the  properties  of  the 
substance  which  we  had  previously  seen  to  regulate  the 
quantity  and  nature  of  the  juice  when  physiologically 
excited  to  flow.  If  we  pretended  to  throw  in  sand,  a 
watery  saliva  escaped  from  the  mucous  glands ;  if  food, 
a  slimy  saliva,  and  if  the  food  were  dry  —  for  example, 
dry  bread  —  a  large  quantity  of  saliva  flowed  out,  even 
when  it  excited  no  special  interest  on  the  part  of  the 
dog.  When,  on  the  other  hand,  a  moist  food  was  pre- 
sented —  for  example,  flesh, —  much  less  saliva  appeared 
than  in  the  previous  case,  however  eagerly  the  dog  may 
have  desired  the  food.  This  latter  eff'ect  is  particularly 
obvious  in  the  case  of  the  parotid  gland."  ^ 

More  than  this  the  psychical  excitation  may  be  part 
of  a  wider  complex;  everything  that  is  in  any  way  psy- 
chologically associated  with  an  object  which  physiolog- 
ically excites  the  saliva  reflex  may  also  produce  it, — 
the  plate  which  customarily  contains  the  food,  the  fur-  , 
niture  upon  which  it  stands,  the  person  who  brings  it, 
even  the  sound  of  the  voice  and  sound  of  the  steps  of  ^ 
this  person.^ 

"  Any  ocular  stimulus,  any  desired  sound,  any  odor 
that  might  be  selected,  and  the  stimulation  of  any  part 
of  the  skin,  either  by  mechanical  means  or  by  the  appli- 
cation of  heat  or  cold,  have  in  our  hands  never  failed  to 
stimulate  the  salivary  glands,  although  they  were  all  of 
them  at  one  time  supposed  to  be  ineflScient  for  such  a  pur- 
pose. This  was  accomplished  by  applying  these  stimuli 
simultaneously  with  the  action  of  the  salivary  glands, 
this  action  haviAg  been  evolved  by  the  giving  of  certain 
kinds  of  food  or  by  forcing  certain  substances  into  the 
dog's  mouth."  ^ 

iThe  work  of  the  Digestive  Glands  (English  Translation),  p.  152. 

2  J.  P.  Pawlow:  Psychische  Erregung  der  Speicheldriisen,  Ef' 
gebnisse  der  Physiologie,  1904,  /  Abteil,  p.  182. 

3  Huxley  Lecture,  Br.  Med.  Jour.,  Oct.  6,  1906. 


16  PSYCHOTHERAPEUTICS 

It  is  obvious  that  reflex  excitation  thus  having  been 
accomplished  by  the  education  of  the  nerve  centers  to 
a  previously  indiff^erent  stimulus  the  reproduction  of  the 
process  through  this  stimulus  is  in  principle  an  act  of 
physiological  memory.^ 

In  man  as  an  example  may  be  cited  the  vesical  reflex 
which  may  similarly,  as  is  well  known,  be  educated  to 
react  to  the  sound  of  running  water. 

These  pathbreaking  demonstrations  of  Pawlow  fur- 
nish the  key  to  the  mechanism  of  many  neuroses  and 
psychoses,  for  indeed  the  educated  reactions  of  the  gas- 
tric and  salivary  glands  to  ordinarily  indiff'erent  stimuli 
from  the  environment  and  to  psychical  states  are  in 
reality  nothing  but  an  artificially  created  psycho- 
neurosis  —  a  perversion  of  the  normal  reactions.  Such 
artificial  syndromes  render  comprehensible  the  mechan- 
ism of  such  neuroses  as  the  well-known  neurotic  type  of 
hay  fever  which  belongs  to  the  association  neuroses.^ 

In  this  type  the  whole  physiological  group  of  func- 
tions composing  the  neurosis  —  lachrymation,  conges- 
tion of  the  mucous  membranes  and  erectile  tissues,  se- 
cretions, cough,  dyspnoea,  etc., —  are  linked  into  an  auto- 
matically working  mechanism  by  repetition  and  excited 
by  a  stimulus  from  the  environment,  e.  g.,  the  sight  of 
a  rose  (which  may  be  artificial),  dust,  sunlight,  etc. 
Psychical  expectation  (auto-suggestion)  of  course  pre- 
pares  and  keeps   alive   the   association.     This   neurosis, 

1  Prince:  The  Unconscious,  Journal  of  Abnormal  Psychology,  Oct.- 
Nov.,  1908. 

2  Morton  Prince:  Association  Neuroses,  Journal  of  Nervous  and 
Mental  Disease,  May,  1891. 

2  Morton  Prince:  Hay  Fever,  Due  to  Nervous  Influences,  Oc- 
curring in  Five  Members  of  the  same  Family,  Annals  of  Gyne- 
cology and  Pediatry,  1895. 

2jolm  E.  Donley:  Three  Cases  of  Association  Neuroses,  Bos- 
ton Medical  and  Surgical  Journal,  November  3,  1904;  Study  of  As- 
sociation Neuroses,  Journal  op  Abkobmal  Psychology,  Vol.  II, 
p.  45. 


FIELD  OF  PSYCHOTHERAPY  17 

composed  mostly  of  physical  symptoms,  strikingly  illus- 
trates the  principle  of  an  educated  functional  disease  and    _^^ 
typifies  many  forms  of  neuroses. 

In  other  psycho-neuroses  the  syndrome  may  be  made 
up  partly  of  psychical  elements  and  partly  of  physical 
processes.  This  is  seen  in  psychasthenia,  where,  for  in- 
stance, fears,  anxieties,  scruples,  confusion  of  thought,  / 
etc.,  are  associated  with  all  sorts  of  disturbances  of  the 
body, —  dizziness,  palpitation,  tremor,  perspiration  — 
the  whole  constituting  a  phobia  or  anxiety  neurosis. 

Now  without  pursuing  these  illustrations  further,  the 
point  I  would  like  to  emphasize  is  that  the  whole  process 
by  which  these  functional  syndromes  are  created  is  edu-  ( 
cational.  The  education  may  be  unintentional,  i.e.,  acci- 
dental, as  in  the  hay  fever  neurosis  and  those  resulting 
from  continued  auto-suggestion;  or  it  may  be  inten- 
tional, as  in  Pawlow's  experiments  on  the  digestive  func- 
tions. 

In  these  facts  which  I  have  only  incompletely  collated 
we  have  the  manifestations  of  a  broad  general  principle 
governing  nervous  processes  in  normal  and  abnormal 
life.  It  is  tV>p  prinrip]^  of  pedagogy.  Unless  nervous 
processes  could  be  artificially  linked  into  coaptative 
synergetic  systems  adapted  to  a  purpose,  education  in 
any  field  would  be  impossible.  Intellectual  acquisitions, 
from  the  repetition  of  the  alphabet  to  a  complete  knowl- 
edge of  a  language  or  a  science,  and  physiological  ac- 
quisitions, from  the  use  of  a  tool  to  the  mastery  of  the 
piano  or  the  vocal  apparatus,  not  only  would  be  unknown 
but  would  be  unthinkable.  The  education  of  the  mind 
and  body  depends  upon  the  artificial  synthesizing  of 
functions  into  a  complex  adapted  to  an  end  or  useful 
purpose.  By  the  same  principle  functions  may  be  synthe- 
sized by  education  into  a  complex  which  does  not  serve 
a  useful  purpose  but  rather  is  harmful  to  the  individual. 


18  PSYCHOTHERAPEUTICS 

When  this  is  the  case  we  call  it  abnormal  or  a  psycho- 
neurosis. 

From  this  point  of  view  how  inadequate  is  the  allega-; 
tion  which  we  often  see  stated  that  there  is  no  such  thing 
as  a  functional  disease.  What  can  be  the  conception  of 
function  which  must  be  held  by  those  who  maintain  such 
a  theory  is  something  that  passes  comprehension.  A 
functional  disease  is  a  perversion  of  the  normal  proc- 
esses brought  about  by  some  acute,  intense  experience  or 
by  repetition  of  an  experience,  i.e.,  by  education.  The- 
oretically it  would  follow  that  what  can  be  done  by  edu- 
cation can  be  undone  by  the  same  method,  and  in  practice 
we  find  this  to  be  true.  We  shall  presently  see  that  there 
are  often  types  of  functional  disease,  but  each  is  based 
on  a  perversion  of  the  normal  mechanism. 

2.       CONSERVATION 

Another  principle  or  tendency  of  the  functioning  of 
the  nervous  system  has  been  firmly  established  by  re- 
peated experimentation  and  observation.  Its  impor- 
tance for  psychotherapy  can  hardly  be  exaggerated.  It 
is  this :  All  our  experiences  —  anything  that  we  have 
thought,  seen,  heard,  or  felt  —  tend  to  be  conserved  ii 
V  such  a  way  that  they  can  be  reproduced  in  a  form  ap^ 
proaching  that  of  the  original  experience.  Upon  this 
meniorydepends.  It  is  evident  that  we  never  could  re- 
member anything,  that  all  experiences  would  be  lost  to 
consciousness,  unless  somehow  and  somewhere  they  were 
preserved,  unless  there  was  some  physical  arrangement 
for  preserving  them.  In  what  form  mental  and  other 
experiences  are  conserved  we  do  not  know,  we  can  only 
theorize;  but  we  must  infer  that  some  kind  of  residue  or 
impression,  chemical  or  physical,  is  left  in  the  neurones 
in  consequence  of  which  they  have  a  disposition  to  repro- 
duce,   when    again    stimulated,    the    original    experience, 


FIELD  OF  PSYCHOTHERAPY  19 

whether  an  idea  or  physiological  reaction.  Hence  these 
residues  are  called  unconscious  "  residua  "  or  "  disposi- 
tions." They  have  a  hypothetical  existence  like  the 
atoms  and  molecules  of  physics,  but  upon  them  the  theory 
of  memory  is  based.  They  may  be  likened  to  the  impres- 
sions left  in  the  wax  cylinder  or  the  magnetization  of  the 
wire  of  the  phonograph  by  the  spoken  word.  A  complex 
of  such  residua  is  an  "  unconscious  complex." 

But  besides  mental  experiences  all  observation  and  ex- 
perimentation show  that  pure  physiological  reactions  as- 
sociated with  a  given  mentar  experience  are  conserved  as 
a  part  of  that  association.  The  ideas,  for  example,  be- 
longing to  a  fright  complex  which  originally  were  accom- 
panied by  palpitation  of  the  heart,  tremor,  perspiration, 
muscular  weakness,  etc.,  when  reproduced  in  memory  are 
again  accompanied  by  all  these  physiological  reactions. 
So  in  Pawlow's  dogs  the  repeated  experiences  of  a  sen- 
sation of  touch,  accompanied  with  the  physiological 
reactions  of  saliva,  became  a  complex  which  was  con- 
served and  reproduced  on  subsequent  occasions.  The 
nervous  system  faithfully  conserves  and  reproduces  its 
experiences.  Conservation  is  fundamental  for  educa- 
tion ;  for  upon  it  the  law  of  linking  of  complexes  depends. 
It  is  obvious,  for  instance,  that  the  education  of  coap- 
tative  synergesis  of  muscular  movements  for  purposeful 
acts  would  be  impossible  unless  by  the  act  of  experience 
something  capable  of  reproduction  were  impressed  upon 
the  neurones.  Now  the  more  often  an  experience  is  re- 
peated and  the  stronger  its  emotional  tone,  the  more 
likely  it  is  to  be  conserved.  Thus  we  repeat  a  verse  or 
a  rule  of  grammar  until  we  know  it  by  heart ;  or  we  re- 
peat a  movement  until  it  becomes  automatic. 

But  without  repetition  the  elements  of  an  experience 
may  become  linked  and  conserved.  We  undergo  an  emo- 
tional experience  accompanied  by  various  bodily  reactions, 


\ 


20  PSYCHOTHERAPEUTICS 

as  in  a  railroad  accident,  or  we  experience  an  abhorrent 
idea,  or  one  of  apprehension,  or  repulsive  desire  —  in 
each  case  the  nervous  organism  remembers  the  experi- 
ence and  upon  proper  stimulus  can  reproduce  it.  The 
emotional  tone  seems  to  intensify  the  impression  on  the 
brain  organization. 

Further,  on  the  principle  just  described  of  the  linking 
together  of  experiences  into  complexes,  or  associated 
groups  of  ideas,  feelings,  and  physiological  reactions,  it 
is  evident  that  large  unconscious  complexes,  representing 
experiences,  may  be  conserved  and  afterward  reproduced 
as  a  whole  by  stimulation  of  the  neuron  residua.  Ob- 
servation shows  that  this  is  exactly  what  happens ;  and 
when  these  complexes  are  of  an  unhealthy  kind  we  call 
them  obsessions,  phobias,  etc.,  which  in  reality  are  noth- 
ing but  experiences  faithfully  conserved  as  residua  and 
reproduced  from  time  to  time.  They  may  also  be  called 
association  psychoses  or  neuroses  on  the  basis  of  their 
mechanism. 

Now  another  fact  which  has  been  proved  by  experi- 
mentation and  observation:  A  complex,  i.e.,  the  uncon- 
scious residua  of  a  complex,  may  be  almost  photograph- 
ically conserved  notwithstanding  that  we  may  not  be  able 
to  voluntarily  reproduce  it,  i.e.,  recall  the  original  ex- 
perience. It  may  be  preserved  in  the  unconscious 
neurons  and  be  made  to  reproduce  itself  by  some  special 
device.  E.g.,  a  childhood  experience  may  be  entirely 
forgotten,  yet  that  it  may  be  still  preserved  is  shown  by 
the  fact  that  it  can  be  recalled  in  even  all  its  minute  de- 
tails in  hypnosis,  dreams,  etc.  When  recalled  in  dreams 
it  often  takes  on  a  distorted  form  and,  freed  from  a  true 
appreciation  of  its  meaning,  it  awakens  the  liveliest  and 
often  terrifying  emotions.  This  latter  is  a  matter  of 
considerable  significance,  for  the  same  principle  plays  a 
part  in  hysterical  crises. 


FIELD  OF  PSYCHOTHERAPY  21 

Another  fact  of  observation  needs  to  be  grasped  in  all 
its  significance,  for  it  underlies  one  practical  method  of 
psychotherapy.  The  failure  to  appreciate  this  has  led 
to  misunderstandings  of  the  principle  of  hypnotic  sug- 
gestion and  indirectly  to  a  denial  that  such  suggestions 
are  of  therapeutic  value,  while  at  the  same  time  it  is  ad- 
mitted that  waking  suggestion  is  efficacious.  The  fact 
is  this :  It  makes  no  difference  in  what  state  complexes  are 
formed,  whether  in  every  day  life,  in  sleep,  trance,  dis- 
sociated personality,  subconscious  states  or  hypnosis, 
they  are  or  may  be  equally  firmly  organized  and  con- 
served, and  they  are  conserved  whether  we  can  volun- 
tarily recall  the  experiences  or  not.  Whether  they  are  to 
become  organized  depends  upon  the  mode  and  conditions 
under  which  the  impression  is  made  upon  the  mind  or  nerv- 
ous system,  but  once  organized  they  are  conserved  and 
become  a  part  of  our  personality.  We  cannot  get  rid 
of  them  unless  they  are  eff*aced  by  the  corroding  action 
of  time  or  disease.  We  are  accustomed  to  think  of  ex- 
periences belonging  to  such  states  as  not  belonging  to 
ourselves.  This  is  a  mistake.  All  experiences,  however, 
and  wherever  formed,  if  conserved,  are  a  part  of  our- 
selves and  belong  to  the  storehouse  of  our  knowledge, 
though  we  may  or  may  not  afterwards  draw  upon  that 
storehouse  in  practical  life.  We  know  that  dreams  which 
are  ^lot  even  remembered  may  be  not  only  conserved  but 
may  influence  the  personality  during  quite  long  periods 
of  time  for  good  or  for  ill.  I  have  now  a  case  under 
observation  where  an  idea  complex  occurring  in  a  dream 
persisted  after  waking  as  an  obsession,  and  has  contin- 
ued as  such  to  the  present  time,  a  period  of  twelve  years. 

If  a  complex,  then,  of  ideas,  which  make  up  points  of 
view,  attitudes  of  mind,  beliefs,  hopes,  and  aspirations, 
is  once  firmly  formed  and  organized  in  hypnosis,  it  re- 
mains as  a  part  of  our  personality. 


/ 


2«  PSYCHOTHERAPEUTICS 

Further,  experimentation  and  clinical  observation  have 
conclusively  proven  that  a  complex  of  ideas  formed  in 
hypnosis,   whether   remembered   when   the   personality   is 

\  awake  or  not,  can  affect,  modify,  or  determine  the  ideas, 
beliefs,  feelings,  emotions,  etc.,  of  the  individual.  The 
elements  of  the  hypnotic  complex  enter  the  stream  of 
thought  of  every-day  life  and  modify  it.  Whether  it  will 
do  so  or  not  depends  on  various  conditions.  How  it  does 
so  is  another  question  which  we  cannot  enter  into  here. 
That  it  may  do  so  is  a  fact  which  can  be  proven  as  often 
as  we  wish  to  try  the  experiment.  If  this  is  so  when 
there  is  complete  amnesia  after  waking  from  hypnosis 
it  can  be  understood  how  much  more  easily  it  may  be  the 
case  when,  as  happens  in  nine  tenths  of  such  procedures, 

\  hypnosis  is  little  more  than  a  state  of  relaxation  and  ab- 
straction and  is  not  followed  by  amnesia,  but,  on  the  con- 
trary, the  whole  hypnotic  experience,  all  the  ideas  of  the 
complex  which  were  therein  formed  are  remembered  by 
the  subject.  When  it  is  remembered  that  in  hypnosis 
there  is  increased  suggestibility,  and  that  there  may  be 
induced  a  dissociation  of  all  ideas  which  clash  with  and 
antagonize  the  suggested  ideas,  thereby  allowing  a  new 
synthesis  to  be  formed,  we  can  see  what  a  powerful  influ- 
ence can  be  exercised  on  the  personality  by  this  pro- 
cedure. 

3.       DISSOCIATION 

The  next  principle  to  which  I  would  call  your  atten- 
tion is  one  to  which  I  have  already  referred  above,  namely 
dissociation.  It  is  a  general  principle  governing  the  nor- 
mal psycho-nervous  mechanism  and  therefore  in  a  highly 
marked  form  only  is  pathological.  A  characteristic  t3^pe 
is  functional  amnesia  by  which  an  epoch  or  a  long  period 
of  time  is  blotted  out  of  the  memory.  You  will  recall 
cases  where  following  an  emotional  trauma  the  preceding 


\ 


FIELD  OF  PSYCHOTHERAPY  2^ 

hours  or  days  or  months  are  forgotten.  The  experi- 
ences of  this  time  cannot  be  recalled  as  memories;  but 
they  are  still  preserved  as  brain  residua,  for  they  can  be 
reproduced  by  artificial  means  through  hypnosis  and 
other  methods.  The  amnesia  for  the  hypnotic  state  and 
dreams  after  waking  is  also  due  to  the  same  principle,  as 
is  also  that  following  numerous  other  states  which  I  can- 
not spare  the  time  to  mention  here.  What  has  happened 
in  such  conditions  is  a  dissociation  between  the  systems 
of  brain  residua  which  correspond  to  the  psychological 
experiences.  There  is  an  inability  to  synthesize  these 
systems  into  one  personality  and  hence  the  amnesia. 

Amnesia,  of  course,  as  a  technical  term,  includes 
only  ideas,  but  dissociated  systems  or  complexes  may  in- 
clude motor  and  sensory  functions,  and  these  we  meet 
with  as  paralyses  and  anesthesias  as  observed  in  hysteria. 
That  such  dissociations  are  purely  functional  is  shown 
by  the  fact  that  they  can  be  produced  by  suggestion  and 
removed  (synthesis)  by  suggestion.  When,  as  some- 
times happens,  a  single  symptom  like  paralysis  and  anes- 
thesia cannot  be  removed  by  suggestion,  if  the  whole  dis- 
sociated system  to  which  this  symptom  belongs  is  synthe- 
sized by  suggestion  the  symptom,  paralysis  or  anesthesia, 
disappears.  Here  again  we  have  a  fact  important  for 
psychotherapeutics, —  the  fact  that  we  can  produce  dis-^ 
sociation  and  synthesis  by  suggestion, —  for  if,  as  experi- 
mental investigation  has  shown,  the  basis  of  certain 
psycho-pathological  conditions  like  hysteria  is  dissocia- 
tion, we  have  a  means  at  our  command  which  may  be  used 
for  the  resynthesizing  of  the  personality,  i.e.,  the  res- 
toration of  the  normal  individual.  It  is  important  not 
to  lose  sight  of  the  fact  that  dissociation  is  a  function  of 
the  normal  mechanism  of  the  mind  and  nervous  system, 
and  is  made  use  of  in  normal  life  for  the  adaptation  of 
the  individual  to  the  constant  and  ceaseless  changes  of 


U  PSYCHOTHERAPEUTICS 

the  environment.  It  is  the  enormous  exaggeration  and 
perversion  of  this  dissociating  mechanism  that  consti- 
tutes abnormality.  A  suggested  idea  simply  stimulates 
and  makes  use  of  the  normal  mechanism,  otherwise  it  can 
have  no  effect. 

Among  the  normal  phenomena  of  dissociation  are  to 
be  reckoned  temporary  and  some  permanent  forms  of 
forget  fulness,  the  limitation  of  the  field  of  consciousness 
in  absent-mindedness,  moods,  anger,  and  other  strong 
emotional  states  and  sleep.  Amongst  the  artificial  and 
pathological  conditions  characterizing  largely  or  chiefly 
the  dissociations  are  hypnotic  and  hypnoidal  states;  sug- 
gested and  hysterical  amnesia,  paralyses,  contractures, 
anesthesia?,  etc. ;  somnambulism,  trance,  psycholeptic  at- 
tacks, etc. 

Emotion,  again,  is  a  powerful  factor  in  producing  dis- 
sociation as  well  as  the  linking  and  conservation  of  com- 
plexes. 

In  the  so-called  neurasthenic  state  and  hysteria,  disso- 
ciation plays  a  very  important  part.  All  cases  of  hys- 
teria and  many  of  neurasthenia  are,  as  I  see  the  matter, 
cases  of  dissociated  personality,^  but  it  would  carry  us 
too  far  from  our  main  subject  to  discuss  this  aspect  of 
the  matter  at  this  time. 

Subconscious  Ideas,  There  are  certain  important  phe- 
nomena of  dissociation  and  conservation  that  ought  not 
to  be  omitted,  considering  the  important  part  which  they 
sometimes  play,  and  the  large  amount  of  attention  which 
they  have  received. 

When  the  conserved  residua  of  an  unconscious  com- 
plex are  stimulated,  this  complex  becomes  a  conscious 
memory  of  which  we  are  aware,  but  sometimes  something 

5  Morton  Prince:  Hysteria  from  the  Point  of  View  of  Disso- 
ciated Personality,  Jouenal  or  Abnorsial  Psychology,  October, 
1906. 


FIELD  OF  PSYCHOTHERAPY  25 

else  happens  —  it  becomes  a  conscious  memory  of  which 
we  are  not  aware.  Ideas  are  awakened,  but  we  are  not 
aware  of  them.  These  are  what  are  called  subconscious, 
or  better,  co-conscious  ideas,  which  means  ideas  disso- 
ciated from,  split  off  from  the  main  consciousness.  This 
is  an  interpretation  of  certain  phenomena  belonging  to 
abnormal  psychology  which  would  carry  us  too  far  afield 
to  consider  here;  but  the  evidence  is  so  strong  that  it  is 
impossible  to  resist  the  conclusion.  Now  when  this  is  the 
case  such  ideas  often  resemble  dreams  —  fixed  dreams. 
The  ideas,  like  dreams  freed  from  the  control  of  the  per- 
sonal consciousness  which  has  no  appreciation  of  their 
existence  or  meaning,  take  on  a  distorted  form,  and  when 
accompanied  by  emotions  acquire  all  the  characteristics 
of  nightmares  —  subconscious  nightmares  they  may  be 
called.  That  they  should  produce  psychological  and 
mental  disturbances  is  not  to  be  wondered  at.  This  is 
what  is  sometimes  found  in  hysteria  when  they  produce 
the  so-called  hysterical  crises.  To  get  rid  of  such  sub- 
conscious nightmares  must  plainly  be  an  object  for  psy- 
chotherapy. A  simple  type  of  the  dissociated  co-con- 
scious idea  is  found  in  hysterical  anesthesia.  Here  there 
is  no  absolute  anesthesia.  The  lost  tactile  sensations  are 
only  split  off  from  the  personal  consciousness  and,  al- 
though the  patient  is  unaware  of  them,  they  are  pre- 
served as  co-conscious  perceptions  or  tactual  ideas.  To 
resyntheslze  these  perceptions  with  the  personal  con- 
sciousness is  to  make  the  patient  aware  of  them  and  re- 
move the  anesthesia. 

I  pass  over  as  a  controversial  matter  the  mechanism 
by  which  co-conscious  ideas  are  dissociated  from  the  main 
content  of  the  personal  consciousness,  i.e.,  by  which  the 
person  becomes  no  longer  aware  of  them.  Differing  views 
are  maintained.  By  some  it  is  held  that  in  disease,  as  In 
hysteria,  the  splitting  of  the  mind  is  due  to  fatigue  and 


£6  PSYCHOTHERAPEUTICS 

emotional  trauma;  by  others  that  it  is  due  to  the  direct 
volitional  repression,  or  the  pushing  out  of  conscious- 
ness of  ideas  which  are  unacceptable  to  the  individual. 
But  whichever  mechanism  is  the  correct  one,  whether  dis- 
sociation is  brought  about  by  voluntarily  repressing 
painful  or  unacceptable  ideas  or  whether  by  an  over-in- 
tense stimulus  from  an  emotional  trauma  to  which  the 
individual  is  not  adapted,  or  by  fatigue,  in  any  case  the 
pathological  dissociation  is  but  an  exaggeration  or  per- 
version of  a  normal  dissociating  mechanism.  That  it 
still  remains  functional  is  shown  by  the  fact  that  a 
functional  stimulus  (suggestion)  is  capable  of  producing 
it  and  removing  it.  We  have  here  a  type  of  functional 
disease  which  is  somewhat  different  in  form  from  that 
which  results  from  the  educational  process,  although  this 
may  come  later  into  play  in  evolving  subsidiary  symp- 
toms. I  hardly  need  point  out  that  the  secondary  effects 
of  dissociation  —  hysterical  stigmata,  etc. —  are  but  the 
products  of  the  normal  functioning  of  the  mutilated  and 
dissociated  fragments  of  the  personality. 

4.       AUTOMATISM 

In  the  mechanism  of  normal  psychic  life,  automatism 
plays  a  much  larger  part  than  is  generally  realized. 
This  principle  tends  to  the  economy  of  effort.  We  see  it 
in  habit  actions  and  absent-minded  acts  when  our  atten- 
tion is  directed  to  some  other  train  of  thought  than  that 
engaged  in  the  actions.  Even  language  symbols  tend  to 
become  associated  into  set  phrases  and  formulas,  which 
tend  to  become  automatic  and  labor-saving  devices  for 
the  expression  of  thought.  In  expletives  and  explosive 
phrases  which  almost  unconsciously  give  vent  to  our  feel- 
ings we  easily  recognize  these  language  automatisms. 
Less  conspicuous  as  automatisms  is  the  activity  of  com- 
plexes of  ideas,  however  formed,  which  function  more  or 


FIELD  OF  PSYCHOTHERAPY  %n 

less  automatically  as  a  group  and  determine  the  direc- 
tion of  our  thought  and  its  content.  The  association 
experiments  have  done  much  to  bring  to  light  this  auto- 
matic activity  of  complexes,  and  we  are  under  deep  obli- 
gations to  Freud,  Bleuler,  and  Jung  for  having  directed 
our  attention  to  this  principle  and  emphasized  these  par- 
ticular facts.  In  pathological  fixed  ideas  which  rush 
into  consciousness  unbidden  and  undesired  we  can  clearly 
see  this  automatic  activity.  So  in  establishing  fixed  hab- 
its of  thought,  in  forming  deeply  rooted  ideas  and  points 
of  view,  beliefs,  etc.,  we  form  complexes  which  are  cap- 
able of  more  or  less  autonomous  action. 

When  psychological  and  physiological  processes  be- 
come dissociated,  and  thereby  freed  from  the  inhibitory 
control  of  the  personal  consciousness,  automatism  is  ob- 
served in  its  most  highly  developed  form.  The  split  off 
groups  of  psychological  or  physiological  elements  ac- 
quire what  may  be  called  a  hyper-excitability  and  are 
capable  of  extremely  independent  functioning.  The 
manifestations  may  be  in  the  form  of  subconscious  ideas, 
hallucinations  (sensory  automatisms),  tics,  spasms,  con- 
vulsions, contractures  (motor  automatisms),  etc.  Pri- 
marily such  pathological  phenomena  depend  upon  disso- 
ciation of  the  nervous  organism  and  the  stimulus  by  some 
excitation  from  within  or  without  of  the  nervous  mechan- 
ism involved.  With  reassociation  and  cessation  of  stim- 
ulus the  automatisms  logically  cease.  The  aim  of  psy- 
chotherapy, therefore,  must  plainly  be  to  reassociate  the 
split  up  personality,  and  to  form  such  healthy  complexes 
of  ideas  as  will  not  stimulate  the  undesired  complexes, 
but  by  their  automatic  activity  will  contribute  to  the 
well-being  of  the  individual  and  adapt  him  to  his  environ- 
ment. 

6.       EMOTIONAL    ENERGY 

It  is  a  fact  of  observation  that  intense  sthenic  emo- 


^  PSYCHOTHERAPEUTICS 

tions  and  feelings  are  accompanied  by  an  increase  of  the 
vital  functions  while,  per  contra,  certain  depressive  emo- 
tions and  feelings  are  accompanied  by  a  decrease  of  the 
vital  functions.  Further,  it  is  generally  recognized  by 
psychologists  that  most,  if  not  all,  ideas  have  a  feeling 
tone  attached  to  them.  Consequently  if  certain  com- 
plexes of  ideas  which  have  intense  sthenic  feeling  tones 
are  brought  into  the  personal  consciousnesi?  there  is 
awakened  a  state  of  energy,  a  feeling  of  wellbeing  and 
capacity,  and  an  invigoration  of  the  whole  organism. 
If,  on  the  other  hand,  complexes  of  ideas  which  have  de- 
pressive or  distressing  feeling  tones  are  brought  into 
the  personal  consciousness,  the  contrary  effect  is  pro- 
duced. Stating  the  same  fact  in  another  way,  exalting 
emotions  have  an  intense  synthesizing  effect  while  de- 
pressing emotions  have  a  disintegrating  effect.  This 
last  we  see  exemplified  in  emotional  trauma  (traumatic 
neuroses)  where  sometimes  a  complete  dissociation  or 
splitting  of  the  personality  occurs,  being  manifested  by 
altered  personality,  anesthesia,  paralysis,  etc.  Every 
one  who  has  studied  the  hypnotic  states  must  have  ob- 
served these  phenomena  experimentally  produced.  With 
the  in  rushing  of  depressive  memories  or  ideas  whether 
originating  autochthonously  in  the  associations  of  the 
mind  of  the  patient,  or  accidentally  or  intentionally  sug- 
gested by  the  experimenter,  there  is  suddenly  developed 
a  condition  of  fatigue,  illbeing,  and  disintegration,  fol- 
lowed after  waking  by  a  return  or  accentuation  of  all 
the  neurasthenic  symptoms.  If  on  the  other  hand  exalt- 
ing ideas  and  memories  are  introduced  and  brought  into 
the  limelight  of  attention  there  is  almost  a  magical  re- 
versal of  the  process.  The  patient  feels  strong  and 
energetic,  the  neurasthenic  symptoms  disappear,  and  he 
exhibits  a  capacity  for  sustained  effort.  He  becomes 
revitalized  so  to  speak.     This,  I  believe,  is  the  secret  of 


FIELD  OF  PSYCHOTHERAPY  29 

those  changes  of  character  and  physical  capacity  which 
William  James  has  so  brilliantly  illuminated  in  his  essay 
on  the  "  Energies  of  Men."  Complexes  of  ideas  accom- 
panied by  strong  feeling  tones  which  have  long  lain  fal- 
low are  brought  out  of  their  dormant  abode  and  made  to 
become  a  part  of  the  working  force  of  the  mental  fac- 
tory. 

In  this  principle,  then,  we  see  a  mechanism  which  tends 
to  the  development  of  the  neuroses  and  psychoses  on  the 
one  hand,  and  to  states  of  invigorating  health  on  the 
other,  according  as  whether  disintegrating  or  synthesiz- 
ing emotions  and  feelings  are  brought  into  the  conscious 
field  of  the  individual.  In  the  hypnoidal  state  of  Sidis 
and  in  hypnosis  it  is  particularly  easy  to  bring  out  of 
the  dormant  consciousness  into  this  active  central  field 
memories  and  ideas  which  have  been  pushed  aside  or  upon 
which  the  individual  has  lost  his  grip  by  reason  of  their 
having  become  dissociated  by  fatigue,  friction  with  the  / 
environment,  or  by  other  disintegrating  factors.  It  is 
thus  easy  to  modify  the  personality  at  will  by  measures 
which  make  use  of  this  principle.  The  transformation 
effected  by  the  development  of  energy  in  this  way  is  often 
most  striking  and  is  often  commented  upon  by  the  pa- 
tient. On  the  other  hand,  I  have  observed  that  when  for 
any  reason  depressive  memories  and  such  idea-complexes 
enter  and  remain  in  the  mind  of  the  hypnotized  subject, 
no  matter  what  suggestions  are  given,  the  patient  on 
waking  becomes  or  remains  correspondingly  depressed 
and  neurasthenic. 

I  have  thus  far  briefly  formulated  the  main  psycholog- 
ical principles  upon  which  psychotherapy  rests.  The 
point  I  wish  to  bring  out  into  strong  relief  is  that  these 
principles  or  tendencies  govern  the  normal  functioning 
of  the  psycho-nervous  system,  and  that  it  is  the  perver- 
sion   of    these    tendencies    which    constitute    functional 


30  PSYCHOTHERAPEUTICS 

disease;  that  is  to  say  reactions  which  misadapt  the  in- 
dividual to  his  environment  and  which  result  from  normal 
functioning  under  conditions  to  which  the  individual  is 
not  adapted.  Functional  disease  is  therefore  a  process 
of  perverted  functioning.  Conversely  psychotherapy 
makes  use  of  these  same  principles  or  tendencies  to  re- 
adapt  the  individual  to  his  environment,  to  re-educate 
him  to  healthy  reactions. 

Psychotherapy  simply  makes  use  of  the  normal  mechan- 
ism of  the  mind  and  body,  of  the  physiological  machinery 
to  bring  about  a  restitution  of  the  disordered  functions 
and  restore  the  individual  to  health.  Thus  suggestion 
can  only  act  by  stimulating  the  physiological  mechanism, 
it  can  only  make  use  of  machinery  already  provided;  it 
cannot  create  anything  anew,  do  anything  that  is  not  in 
accord  with  the  laws  of  the  nervous  system.  As  a  method 
psychotherapy  is  comparable  in  every  way  to  what  is 
now  known  as  physiological  therapeutics  which  has  taken 
such  an  important  place  in  modern  treatment  in  internal 
medicine. 

I  fear  my  exposition  has  been  too  brief  to  enable  these 
principles  to  be  clearly  grasped  by  those  who  have  not 
systematically  studied  and  observed  the  phenomena  of 
abnormal  psychology.  The  field  of  investigation  is  a 
wide  one,  and  to  thoroughly  comprehend  the  meaning  of 
the  facts  that  are  to  be  observed  one  must  make  himself 
familiar  with  them  at  first  hand  as  one  would  expect  to 
do  in  bacteriology  if  he  would  understand  the  principles 
of  infectious  disease  and  immunity. 

The  psychological  principles  I  have  attempted  to  elu- 
cidate may  be  summed  up  as:  First,  Complex  formation; 
second.  Conservatism ;  third,  Dissociation ;  fourth.  Autom- 
atism; fifth.  Emotional  Energy. 

Each  of  these  principles  is  made  use  of  by  psycho- 
therapy in  greater  or  less  degree  according  to  the  con- 


FIELD  OF  PSYCHOTHERAPY  31 

ditions  presented.  If  we  are  dealing  with  a  simple  psy- 
cho-neurosis of  the  neurasthenic  type  where  the  dis- 
turbance can  be  traced  to  the  first  class  of  facts  I  have 
mentioned,— i.e.,  to  unhealthy  ideas,  self-examination, 
worry,  erroneous  beliefs  in  and  apprehension  of  disease 
with  the  depressive  emotional  tones  that  go  with  such 
states,  to  habits  of  introspection  and  concentration  of 
the  mind  on  the  functions  of  the  body,  etc., —  the  main 
principle  to  be  made  use  of  is  the  organization  and  sub- 
stitution of  healthy  complexes  in  place  of  the  unhealthy 
ones.  This  is  not  a  simple  procedure,  but  an  art.  It 
often  requires  all  the  skill  which  can  be  acquired  from  a 
knowledge  of  human  nature,  of  life,  the  data  of  abnor- 
mal psychology,  and,  above  all,  from  a  recognition  of 
the  principles  above  formulated.  The  point  of  view,  the 
attitude  of  mind,  the  beliefs,  the  habits  of  thought,  must 
be  modified  by  the  introduction  of  new  points  of  view,  of 
data  previously  unknown  to  the  patient  and  drawn  from 
the  wider  experience  of  the  physician ;  by  instruction  in 
the  meaning  of  symptoms  and  in  their  organization  and 
causes;  by  the  suggestion  of  expectations  that  justly 
may  be  fulfilled ;  of  ambitions  that  ought  rightfully  to  Ibe 
entertained ;  of  duties  to  be  assumed  but  •too  long  neg- 
lected; of  confidence  and  hope;  and,  above  all,  by  the 
suggestion  of  the  emotion  and  joy  that  go  with  success 
and  a  roseate  vista  of  a  new  life.  There  is  no  fact  of 
life  that  does  not  have  more  than  one  aspect,  no  conduct 
that  does  not  have  more  than  one  interpretation,  no 
judgment  that  does  not  have  an  alternative,  no  conduct 
that  does  not  have  more  than  one  relation.  Thus  the 
old  systems  of  ideas  carrying  with  them  apprehensions, 
anxieties,  and  depressive  emotions  are  modified  by  being 
interwoven  with  new  ones,  and  «^w  systems  of  ideas  or 
complexes  are  artfully  created  and  substituted  for  the 
old.     These    systems    should    be    such    as    will    stimulate 


32  PSYCHOTHERAPEUTICS 

healthy  reactions  of  the  body  in  place  of  the  unhealthy) 
perverted  reactions. 

Finally  the  whole  complex,  by  repetition,  emphasis,  and 
the  stimulus  of  emotion,  is  firmly  linked  and  organized 
until  is  becomes  conserved  as  unconscious  brain  residua i 
and  a  part  of  the  individual's  personality.  If  thus  con- 
served it  will  be  reproduced  whenever  stimulated.  To  be 
effective  ideas  must  be  fixed,  conserved,  else  they  become: 
the  sport  of  every  passing  thought  and  feeling.  ButI 
for  this  they  must  be  accepted  and  to  be  accepted  they, 
must  be  the  truth,  as  they  should  be  on  ethical  and  ra- 
tionalistic grounds.  Every  person  can  bear  the  truth 
but  it  should  be  the  whole  truth  and  not  half  the  truth  on 
only  one  aspect  of  the  truth  or  the  truth  that  allows 
erroneous  interpretations.  All  this  therapeutic  pro- 
cedure of  course  means  the  education,  or  perhaps  better, 
the  re-education  of  the  patient.  It  is  the  same  process 
that  in  Pawlow's  dogs  led  to  the  secretion  of  gastric 
juice  and  saliva  by  educated  reactions  to  the  environ- 
ment, and  in  hay  fever  neurotics  to  the  creation  of  the 
coryza  complex  as  a  perverted  reaction  to  mental  and 
physical  stimuli.  Only  the  therapeutic  process  is  the 
association  through  education  of  healthy  ideas  and 
stimuli  that  adapt  the  individual  to  his  environm.ent. 

6.       THE  RELATIVE  ADVANTAGES  OF  EDUCATION  IN  HYPNOSIS 
AND   IN    THE    WAKING   STATE 

This  is  a  much  discussed  question.  One  meets  oftei 
rwith  assertions  rather  than  arguments  which  are  mad^ 
/  with  a  warmth  and  acrimony  of  feeling  that  betokens 
prejudice  rather  than  a  masterly  knowledge  of  the  sub- 
ject. From  the  point  of  view  of  formation  of  complexes 
it  must  be  evident,  if  the  psychological  principles  which 
I  have  set  forth  are  well  grounded,  that  it  matters  little 
in   what   state   these   therapeutic    systems    of   ideas   are 


I 


FIELD  OF  PSYCHOTHERAPY  SS 


formed,  whether  in  hypnosis  or  in  the  waking  state. 
When  once  formed  they  become  a  part  of  our  personal- 
ity and  take  part  in  swelling,  modifying,  and  directing 
the  stream  of  mental  life.  This  can  readily  be  appre- 
hended when  it  is  remembered  that  in  ninety  per  cent  of 
cases  so-called  hypnosis  is  little  more,  as  I  have  already 
said,  than  a  condition  of  abstraction  with  relaxation  in 
which  suggestibility  is  heightened.  On  returning  to  the 
full  waking  state  there  is  complete  memory  of  the  whole 
hypnotic  episode,  so  that  the  suggested  ideas  are  accu- 
rately remembered.  As  a  matter  of  fact  hypnosis  is  only 
necessary  in  a  small  minority  of  cases.  In  obstinate 
cases  hypnosis  has  the  advantage  that,  suggestibility  be- 
ing increased  and  antagonistic  ideas  being  dissociated  or 
inhibited,  the  new  ideas  are  more  readily  accepted  and 
the  complexes  more  easily  and  firmly  organized.  Then, 
after  waking,  the  patient  who  remembers  the  suggested 
complexes  finds  that  his  whole  state  of  mind  is  modified. 
But  even  when  amnesia  follows  after  waking  the  result 
is  the  same.  Then  ^  on  examination  we  find,  however 
complicated,  that  the  suggested  ideas  and  emotions 
weave  themselves  into  the  thoughts  of  the  conscious  in- 
dividual and  modify  them;  or  the  emotions,  alone,  may 
intrude  themselves  and  determine  the  mood  and  the  whole 
psychic  content.  To  take  an  actual  case,  I  suggest  to 
B.  C.  A.,  in  hypnosis,  ideas  of  wellbeing,  of  recovery  from 
her  infirmity ;  I  picture  a  future  roseate  with  hope,  stim- 
ulate her  ambitions  with  suggestions  of  duties  to  be  per- 
formed, deeds  to  be  accomplished.  With  all  this  there 
goes  an  emotional  tone  of  exaltation  which  takes  the 
place  of  the  depression  and  of  the  sense  of  failure  pre- 
viously present.  This  emotional  tone  gives  increased 
energy  to  her  organization,  revitalizing,  as  it  were,  her 

6  Cf.    The    Unconscious,    Journal    of    Abnormal    Psychology, 
April  — May,  1909. 


T 


34  PSYCHOTHERAPEUTICS 

pyscho-physiological  processes.  The  whole  I  weave  art- 
fully and  designedly  into  a  complex.  Whatever  neurotic 
symptoms  were  previously  present,  I  do  not  allow  to  en- 
ter this  complex.  Indeed,  the  complex  is  such  that  they 
are  incompatible  with  it.  The  headache,  nausea,  and 
other  bodily  discomforts,  pure  functional  disturbances 
in  this  instance,  are  dissociated  and  cease  to  torment. 
After  "  waking,"  there  is  complete  amnesia  for  the  com- 
plex. Yet  it  is  still  organized,  for  it  can  be  recovered 
again  in  hypnosis.  It  is  simply  dormant.  But  the  emo- 
tional tone  still  persists  after  waking  and  invades  the 
personal  synthesis  which  takes  on  a  correspondingly 
ecstatic  tone.  The  aspect  of  her  environment,  her  con- 
ception of  her  relation  to  the  world,  and  her  past,  pres- 
ent, and  future  mental  life  have  become  colored,  so  to 
speak,  by  the  new  feeling,  as  if  under  a  new  light.  But 
more  than  this,  new  syntheses  have  been  formed  with 
new  tones.  If  we  probe  deep  enough  we  find  that  many 
ideas  of  the  dormant  complex  have,  through  association 
with  the  environment  (point  de  repere),  become  inter- 
woven with  those  of  the  previous  personal  consciousness 
and  given  all  a  new  meaning.  A  moment  ago  [her  view 
was  that]  she  was  an  invalid,  incapacitated,  exiled  from 
her  social  and  family  life,  etc.  What  was  there  to  look 
forward  to.?  Now:  What  of  that?  She  is  infinitely  bet- 
ter; what  a  tremendous  gain;  at  such  a  rate  of  progress 
in  a  short  time  a  new  life  will  be  open  to  her,  etc., — 
radically  new  point  of  view.  Now,  too,  she  feels  buoyant 
with  health  and  energy,  ready  to  start  afresh  on  her  cru- 
sade for  health  and  life.  Her  neurotic  symptoms  have 
vanished.  Such  is  the  change  that  she  gratefully  speaks 
of  it  as  the  work  of  a  wizard.  But  the  mechanism  of  the 
transformation  is  simple  enough.  The  exaltation,  arti- 
ficially suggested  in  hypnosis,  persists,  altering  the  trend 
of  her  ideas  and  giving  new  energy.     The  perceptions 


FIELD  OF  PSYCHOTHERAPY  35 

of  her  environment,  cognition  of  herself,  etc.,  have  en- 
tered into  new  syntheses  which  the  introduction  of  new 
ideas,  new  points  of  view  have  developed;  thus  the  con- 
tent of  her  ideas  has  taken  a  definite  precise  shape. 
Whence  came  these  new  ideas?  They  seem  to  her  to  have 
come  miraculously,  for  she  has  forgotten  the  hypnotic 
complex.  But  forgetting  an  experience  is  not  equiva- 
lent to  its  not  having  happened  or  to  that  experience  not 
having  been  a  part  of  our  own  psychic  life.  The  hyp- 
notic consciousness  remains  a  part  of  one's  self  (as  a 
psychological  complex),  however  absolutely  we  have  lost 
awareness  of  it.  Its  experiences  become  fixed  though 
dormant,  just  as  do  the  experiences  of  our  personal  con- 
scious life.  .  .  .  The  mechanism  is  the  same. 

The  following  letter  from  this  patient,  received  by 
chance  after  these  paragraphs  were  written,  well  ex- 
presses the  psychological  conditions  following  hypnotic 
suggestion. 

"  Something  has  happened  to  me  —  I  have  a  new  point 
of  view.  I  don't  know  what  has  changed  me  so  all  at 
once,  but  it  is  as  if  scales  had  fallen  from  my  eyes ;  I  see 

things  differently.     That  affair  at  L was  nothing 

to  be  ashamed  of,  Dr.  Prince.  I  showed  none  of  the 
common  sense  which  I  really  possess ;  I  regret  it  bitterly ; 
but  I  was  not  myself  and  even  as  [it  was]  I  did  nothing 
to  be  ashamed  of  —  quite  the  contrary,  indeed.  .  .  . 
Anyway,  for  some  reason  —  I  don't  know  why,  but  per- 
haps you  do  —  I  have  regained  my  own  self-respect  and 
find  to  my  amazement  that  I  need  never  have  lost  it.  You 
know  what  I  was  a  year  ago  —  you  know  what  I  am  now ; 
not  much  to  be  proud  of,  perhaps,  but  I  am  the  work  of 
your  hands  and  a  great  improvement  on  [my  poor  old 
self].  I  owe  you  what  is  worth  far  more  than  life  itself 
.  .  .  namely,  the  desire  to  live.  You  have  given  me  life 
and  you  have  given  me  something  to  fill  it  with  ...  I 


66  PSYCHOTHERAPEUTICS 

feel  more  like  myself  than  for  a  long  time.  I  am  *  ray 
own  man  again '  so  to  say,  and  if  you  keep  me  and  help 
me  a  little  longer  I  shall  be  well." 

/^  When  dissociation  exists  it  becomes  self-evident  that  a 
restoration  of  the  healthy  organization  can  only  be  at- 
tained by  a  reassociation  of  the  dissociated  functions. 
It  is  obvious  that  subconscious  ideas,  when  disturbing, 
need  either  to  be  so  modified  that  they  cease  to  function, 
i.e.,  to  be  subconscious  and  dissociated,  or  to  be  rein- 
tegrated with  the  personal  consciousness,  i.e.,  brought 
into  the  full  light  of  conscious  knowledge,  and  thereby 
realized  in  all  their  meaning,  rearranged  and  modified; 
just  as  a  dream  becomes  modified  and  loses  its  psycho- 
logical meaning  and  its  physiological  effects  after  waking 
with  a  full  awareness  of  its  falsity.  Disintegrated  per- 
sonality needs  to  be  reassociated  into  a  unified  complete 
personality,  with  full  possession  of  its  faculties  and 
functions,  etc.  There  are  many  empirical  ways  of  doing 
this,  physical  and  psychological,  but  amongst  the  meth- 
ods experience  has  shown  that  there  are  several  psycho- 
logical procedures  which  are  rational  and  prove  effica- 
cious when  physical  and  empirical  methods  fail.  So- 
called  psycho-analysis,  suggestion  in  the  waking  state 
and  abstraction,  in  so-called  hypnoidal  states  and  hyp- 
nosis, mental  and  physical  hygiene,  all  have  proved  to  be 
efficient  in  bringing  about  a  reintegration  of  dissociated 
functions.  But  all  these  methods  are  only  different 
forms  of  education. 

The  principle  of  dissociation  and  association  is  exem- 
plified by  the  process  of  hypnotizing  and  awaking  an  in- 
dividual. Hypnosis  is  dissociation ;  in  awaking  a  person 
what  we  do  is  to  re-synthesize  the  personality  and  to  re- 
store the  normally  functioning  organism. 

Finally  I  would  point  out  that  a  prerequisite  for  such 


FIELD  OF  PSYCHOTHERAPY  87 

psychotherapeutic  measures  is  a  preliminary  painstaking 
and  exhaustive  analysis  of  the  symptoms,  of  the  genesis 
of  the  psychosis,  of  the  logical  relation  of  the  symptoms 
to  each  other  and  to  mental  and  external  causes,  of  the 
pathology  of  the  symptoms  and  their  significance;  what 
are  due  to  auto-suggestion,  what  to  habit  or  education, 
what  to  fatigue,  what  to  true  organic  disease  —  in  short 
the  complete  meaning  or  philosophy  of  the  disease  must 
be  determined.  If,  as  is  often  the  case,  incidents  in 
whf'ch  the  psychosis  developed  or  which  are  the  subcon- 
scious cause  of  repeated  attacks  are  forgotten,  the  memo- 
ries of  these  should  be  revived  by  one  or  the  other  of 
various  technical  methods  of  psycho-analysis.  Only 
through  a  knowledge  gained  in  this  way  in  each  individ- 
ual case  can  a  rational  psychotherapy  be  undertaken. 
After  such  an  analysis  it  is  generally  surprising  to  find 
that  what  at  first  seemed  a  mere  chaos  of  unrelated 
symptoms  will  turn  out  to  be  governed  by  law  and  order. 

'7.       HYSTERIA 

When  we  come  to  deal  with  the  more^profound  psycho- 
neurotic states,  those  of  the  severer  hysterias,  a  some- 
what different  therapeutic  procedure  is  usually  required. 
Here  we  have  to  do  with  dissociations,  often  of  a  pro- 
I  found  type,  with  paralysis,  anesthesia,  alj^rations  of  per- 
I  sonality  and  subconscious  ideas  of  which  th6  patient  is 
I  unaware,  or  unconscious  automatisms  freed  from  the  in- 
I   hibitions  of  a  fully  synthesized  personality.     For  psy- 
i   chotherapy  reassociation  of  the  dissociated  functions  is 
!   the  essential  principle,  although  again  the  formation  of 
i   new  healthy  complexes  is  necessary  to  maintain  the  as- 
I    sociation.     Our  ingenuity  is  often  taxed  to  the  utmost 
I    in  devising  methods  to  reintegrate  the  psycho-physiolog- 
I    ical  personality.     Various  technical  devices  can  be  made 
1   use  of.     I  cannot  go  into  this  here,  as  I  am  only  dealing 


38  PSYCHOTHERAPEUTICS 

with  principles.  Suffice  it  to  say  that  sometimes  rein- 
tegration can  be  formed  in  a  special  state  of  hypnosis; 
sometimes  by  suggestion  in  hypnosis  or  to  the  waking 
personality;  sometimes  by  recalling  to  the  full  light  of 
the  waking  consciousness  the  subconscious  ideas  or 
"  dreams  " ;  sometimes  by  recalling  them  to  the  full  light 
of  the  hypnotic  consciousness,  etc.  By  doing  this  the 
subconscious  "  dream  "  or  fixed  idea  —  generally  a  mem- 
ory of  some  emotional  incident  —  becomes  fully  recog- 
nized as  to  its  meaning  and  character,  and  thereby  inter- 
woven with  the  logical  processes  of  waking  thought;  in 
other  words,  synthesized  into  a  new,  healthy  complex. 
We  see  the  same  principle  when,  on  waking  from  a  night- 
mare, not  only  the  dream  but  the  realization  that  it  was 
a  dream  comes  into  the  full  light  of  consciousness.  With 
this  realization  the  terrors  and  all  the  bodily  disturbances 
cease. 

I  have  pointed  out  that  one  theory  of  the  mechanism 
by  which  ideas  become  dissociated  is  that  of  voluntary 
repression;  the  individual  pushes  out  of  his  conscious- 
ness ideas  which  are  painful  and  unacceptable.  Conse- 
quently it  is  held  by  those  who  adopt  this  theory  that 
those  dissociated  ideas  must  be  resynthesized  with  the 
personality,  i.e.,  brought  to  the  full  light  of  awareness 
—  to  effect  a  complete  and  permanent  cure,  and  that  the 
mere  act  of  making  the  patient  aware  of  them  effects  the 
cure.  To  accomplish  this  a  special  form  of  psycho- 
analysis (Freud's)  has  been  devised,  not  only  to  dis- 
cover the  dissociated  ideas,  but  to  synthesize  them. 

That  this  method  is  often  useful  and  efficacious  will  be 
admitted,  but  its  mode  of  working,  as  I  interpret  it,  is 
not  that  which  those  who  employ  it  suppose.  Like  other 
methods  too,  it  is  not  always  successful  nor  is  it  the  only 
effective  one. 

Thus  it  is  often  not  difficult  by  suggestion,  with  or 


FIELD  OF  PSYCHOTHERAPY  39 

without  hypnosis,  along  the  lines  I  have  described,  to 
effect  a  cure  although  the  patient  never  becomes  aware 
of  the  troubling  ideas.  More  than  this,  it  is  worth  while 
insisting  that  if  psycho-analysis  merely  synthesizes  the 
repressed  ideas  theoretically  it  is  not  the  logical  method 
to  be  employed.  The  assumed  mechanism  would  require 
something  more.  The  repressed  ideas  are  pushed  into 
the  subconscious  because  they  are^n  conflict  with  other 
wishes  and  feelings  of  the  individual;  \^e  latter  rebels 
against  and  will  not  tolerate  them.  Now  if  nothing  more 
were  done  than  to  bring  them  back  into  the  conscious- 
ness of  the  individual  he  still  would  not  tolerate  them  and 
would  push  them  out  again.  Theoretically,  therefore, 
the  method  would  be  useless.  But  in  fact  the  patient 
does,  we  will  say,  tolerate  the  ideas  that  before  were  un- 
bearable; the  conflict  ceases.  Empirically  the  method 
works.  Why?  The  reason  is  simple:  the  complex  of 
ideas  has  been  changed  by  the  technique  of  psycho-analy- 
sis and  by  the  very  act  of  bringing  to  the  light  of  con- 
sciousness the  repressed  ideas  —  an  elaborate  process. 
We  do  more  than  this :  we  give  the  patient  an  insight  into 
the  meaning  of  his  trouble;  we  let  him  see  new  points  of 
view;  we  introduce  new  ideas  and  feelings  into  his  com- 
plexes ;  in  short,  re-educate  him.  It  is  impossible  to 
practice  psycho-analysis  without  doing  this ;  hence,  it  is 
nothing  more  than  a  special  form  of  the  educational 
treatment  and  has  the  same  therapeutic  value. 

When  the  hysterical  manifestations  are  due  to  the 
functioning  of  dissociated  subconscious  ideas  it  is  not 
always  necessary,  as  some  writers  insist,  to  recall  those 
ideas  to  the  personal  waking  consciousness.  It  is  enough 
to  break  up  the  subconscious  complex  or  to  suggest  an- 
tagonistic ideas,  or  to  resynthesize  the  ideas,  in  the  man- 
ner already  described,  into  a  healthy  complex  which  gives 
a  true  appreciation  of  the  facts  which  they  represent. 


40  PSYCHOTHERAPEUTICS 

This  can  be  done  in  hypnosis.  After  waking.,  though 
amnesia  for  the  previous  subconscious  ideas  may  persist, 
the  symptoms  disappear,  for  those  harmful  subconscious 
ideas  which  caused  the  trouble  have  ceased  to  exist. 

Some  hysterical  attacks  are  what  have  been  aptly 
called  by  Boris  Sidis  recurrent  mental  and  psychomotor 
states;  that  is,  dissociations  of  the  personality  and  the 
reproduction  of  systems  of  ideas  which  originally  were 
an  emotional  mental  accident  that  the  patient  once  upon 
a  time  experienced.  These  experiences  have  been  con- 
served as  brain  residua  and  come  to  life  again  from  time 
to  time  as  attacks.  If  a  rearrangement  of  these  con- 
served experiences,  by  education  along  the  lines  already 
laid  down,  can  be  brought  about,  a  disappearance  of  the 
attacks  may  be  expected. 

Hysterical  attacks  that  are  due  to  auto-suggestion  can 
be  removed,  as  a  rule,  by  simple  suggestion.  Automa- 
tisms, like  contractures,  tics,  spasms,  convulsions  and 
crises,  tend  to  cease  with  the  restoration  of  the  fully 
synthesized  personality  if  the  dissociating  apprehensions 
and  emotions  have  been  removed  and  healthy  complexes 
have  been  substituted  therefor. 

Whatever  technical  methods  are  employed,  it  will  be 
found  that  they  are  all  based  on  the  psychological  prin- 
ciples which  have  been  above  discussed. 

It  is  needless  to  insist  that  a  preliminary  psycho-analy- 
sis is,  as  always  in  psychotherapy,  a  prerequisite  pro- 
cedure. 

8.       PSYCHASTHENIA  AND  OBSESSIONS 

In  so-called  psychasthenia  we  are  dealing  with  a  some- 
what different  pathological  condition  from  hysteria. 
Here  we  have  recurrent  mental  states  in  the  from  of  ob- 
sessions, represented  by  doubts,  scruples,  anxieties, 
phobias,  impulsions,  etc.     The  obsessional  ideas  are  pre- 


FIELD  OF  PSYCHOTHERAPY  41 

served  as  brain  residua.  When  stimulated,  instead  of 
becoming  subconscious,  they  enter  the  consciousness  of 
the  principal  personality.  The  obsessional  ideas  occur 
in  the  form  of  attacks  of  which  psycho-analysis  will  not 
only  show  the  origin  and  meaning  but  that  the  attack  in 
each  instance  is  excited  by  association  with  some  related 
thought  which  has  flashed  into  the  mind  or  other  stim- 
ulus from  the  environment.  Apprehension  and  expecta- 
tion, acting  as  auto-suggestion,  play  in  my  experience  a 
predisposing  part  in  the  mechanism.  The  pathology  is 
too  complex  to  go  into  here,  but  the  same  psychological 
principles  underlie  the  psychotherapy,  viz.,  psycho-analy- 
sis and  education,  the  latter  having  for  an  end  the  sub- 
stitution of  healthy  complexes  for  those  organized 
systems  of  associated  ideas  which  have  become  conserved 
as  residua  in  the  unconscious  and  which  reproduce  them- 
selves as  automatisms  over  and  over  again. 


CHAPTER  TWO 

The  Therapeutic  Value  of  Hypnotic  Suggestion 

by  feederic  henry  gerrish,  m.d.,  ll.d. 
Professor  Emeritus  of  Surgery ^  Bowdoin  College 

IT  is  important  that  hypnotic  suggestion  should  not  be 
confounded  with  other  psychotherapeutic  methods  — 
it  is  only  one  of  various  psychic  means  by  which 
curative  results  can  be  attained;  and  in  my  advocacy  of 
it  as  a  valuable  remedy  there  is  no  intention  to  disparage 
or  belittle  any  of  the  other  psychotherapeutic  methods, 
or  even  to  institute  a  comparison  between  it  and  them. 
We  ought  to  have  a  scientific  acquaintance  with  all  of 
them,  so  that  we  can  select  whatever  method  is  best 
adapted  to  any  case  in  which  some  psychic  remedy  is 
needed.  It  is  pertinent  to  remark  at  this  point  that,  as 
hypnotic  suggestion  is  treated  in  this  essay,  it  will  not 
be  included  in  the  topics  of  the  symposium  on  psycho- 
therapy. 

Although  the  history  of  hypnotism  is  intensely  inter- 
esting, nothing  of  it  will  be  given  here,  as  our  space  is 
quite  sufficiently  occupied  with  more  important  matters. 
For  the  same  reason  the  various  theories  which  have  been 
advanced  to  account  for  its  phenomena  will  not  be  re- 
hearsed. My  task  is  to  set  forth  the  practical  useful- 
ness of  hypnotism  in  the  daily  routine  of  medical  work, 
and  to  clear  away  many  misconceptions  which  have  pre- 
vented the  general  employment  of  this  agency. 

We  are  all  amenable  to  suggestion  in  greater  or 
smaller  degree.  The  training  of  the  infant  is  almost 
wholly  by  suggestion.     To  a  less  but  yet  to  a  very  im- 

42 


VALUE  OF  HYPNOTIC  SUGGESTION        43 

portant  extent  the  same  method  is  operative  on  the  older 
child  —  the  example  of  his  associates  in  the  family  or  out 
of  it  is  more  potent  in  the  formation  of  his  -character  and 
habits  than  are  all  the  precepts  that  are  dinned  into  him. 
As  one's  years  increase  the  susceptibility  to  suggestion 
gradually  diminishes,  apparently  just  in  proportion  to 
the  loss  of  naturalness  and  the  cultivation  of  the  artifi- 
cial restraints  which  convention  imposes.  Suggestibil- 
ity is  generally  commensurate  with  simplicity  of  nature. 
In  full  maturity  we  have  become  so  cautious  that  we  in- 
voluntarily distrust  the  suggestions  that  come  to  us  — 
an  incredulous,  perhaps  even  a  cynical,  element  has  crept 
into  our  natures,  which  prompts  resistance  and  demands 
that  reason  shall  be  convinced.  And  yet  some  suggesti- 
bility remains  —  the  hardest  headed  of  us  can  be  reached 
by  a  sufficiently  frequent  and  skilful  repetition  of  a  sug- 
gestion. This  suggestibility  is  the  basis  of  the  benefit 
that  undoubtedly  comes  to  the  patient  from  the  cheer- 
fulness of  the  physician,  from  his  heartening  words,  from 
his  confident  assurance  that  recovery  is  ahead,  from  his 
strong  personality  and  appearance  of  wellbeing  —  for 
health  is,  in  a  measure,  catching,  as  well  as  disease  — 
from  his  irradiation  of  strength,  of  comfort,  and  of  cour- 
age. Now,  in  the  condition  which  is  known  as  hypnosis, 
suggestibility  is  marvelously  increased.  Suggestions 
which  in  the  ordinary  condition  of  the  personality  are 
unheeded,  in  the  hypnotic  state  are  accepted  with  avid- 
ity. So  large  is  this  hospitality  that  almost  any  sug- 
gestion will  be  welcomed  that  is  not  repugnant  to  the 
moral  sense  of  the  hypnotized  person.  This  eagerness 
for  suggestion  may  be  taken  advantage  of  in  therapeu- 
tics. If  the  patient  is  the  victim  of  a  disease  to  which 
the  name  "  functional  "  is  usually  applied,  and  can  be 
hypnotized,  he  has  a  good  chance  of  getting  relief 
through  the  agency  of  suggestion;  if  his  malady  is  or- 


U  PSYCHOTHERAPEUTICS 

ganic,  a  cure  is  not  to  be  expected.  (The  words  "  func- 
tional "  and  "  organic  "  are  here  used  in  their  ordinary 
sense,  as  a  matter  of  convenience.)  For  example,  the 
patient  has  insomnia,  not  due  to  any  appreciable  struc- 
tural change.  He  is  hypnotized,  and  the  suggestion  is 
made  that  he  will  go  to  sleep  as  soon  as  he  goes  to  bed, 
and  remain  in  slumber  a  given  number  of  hours.  He  is 
then  brought  out  of  the  hypnotic  state,  and  experiences 
no  immediate  effect  of  the  treatment.  Perhaps  he  is 
utterly  incredulous,  and  derides  the  idea  that  a  notice- 
able impression  will  follow  the  process.  But,  if  he  is 
as  suggestible  as  the  average,  when  he  goes  to  bed,  he 
tumbles  into  sleep,  and  continues  in  sleep  substantially 
as  predicted;  or,  if  sleep  has  been  suggested  for  a  par- 
ticular hour,  he  goes  to  sleep  when  the  time  comes,  unless 
he  makes  the  most  strenuous  efforts  to  keep  awake  and 
beat  off  his  drowsiness. 

The  hypnotic  state  is  induced  not  because  it  is  in  itself 
curative,  but  because  that  condition  is  peculiarly  favor- 
able to  the  reception  and  retention  of  suggestions.  It 
is  a  question  of  the  relation  of  soil  and  seed.  In  the 
ordinary  waking  state  the  seed  of  suggestion  falls  on  the 
stony  ground  of  indifference,  which  is  hostile  to  its  devel- 
opment, or  on  ground  where  the  rank  weeds  of  conven- 
tional usage  spring  up  and  choke  it;  but  the  hypnotic 
condition  furnishes  the  richest  kind  of  loam  for  sugges- 
tions, and  in  it  they  take  root  and  rapidly  grow  up  and 
bear  fruit  abundantly. 

Hypnosis  should  not  be  regarded  as  an  abnormal,  a 
pathologic  condition  —  it  is  simply  unusual.  Individu- 
als differ  widely  in  their  capacity  for  hypnotization,  for 
at  one  extreme  are  some  who  cannot  be  put  into  that 
state,  and  at  the  other  end  of  the  scale  are  some  who 
seem  to  be  almost  hypnotized  all  of  the  time. 


VALUE  OF  HYPNOTIC  SUGGESTION         45 

1.       METHODS  OF  INDUCING  HYPNOSIS 

Hypnosis  may  be  induced  in  various  ways.  That 
which  will  be  described  has  proved  serviceable.  (It  is  as- 
sumed that  the  patient  consents  to  be  hypnotized,  and, 
more  than  that,  is  willing  to  co-operate  with  the  physi- 
cian.) First,  the  process  is  explained  to  the  patient, 
who  probably  has  hardly  a  single  correct  idea  on  the 
subject,  and  needs  to  have  his  misconceptions  removed. 
He  is  told  a  number  of  things,  such  as  follow: 

1.  That  all  persons  are  more  or  less  amenable  to  sug- 
gestion in  the  ordinary  waking  condition,  as  is  illustrated 
in  many  familiar  ways,  such  as  gaping  involuntarily,  even 
against  one's  strenuous  attempts  to  avoid  it,  on  seeing 
another  yawn ;  beating  time  unconsciously  on  hearing  the 
measured  throb  of  martial  music;  becoming  wildly  ex- 
cited for  no  other  reason  than  that  one's  companions 
are  panic-stricken;  and,  contrariwise,  having  one's  fears 
allayed  by  the  tranquil  appearance  of  his  associates  in  a 
terrible  emergency. 

S.  That,  in  some  way,  the  mental  mechanism  of  which 
is  not  thoroughly  understood,  when  a  person  is  hypno- 
tized, he  accepts  suggestions  more  readily  than  when  he 
is  in  his  usual  condition;  and  that  hypnosis  is  induced 
only  for  the  purpose  of  taking  advantage  of  this  fact, 
and  thus  enabling  the  patient  to  receive  the  benefit  of 
suggestions,  to  which,  in  his  ordinary  mental  state,  he 
is  practically  impervious. 

3.  That  no  harm  to  the  patient  in  any  direction  will 
result  from  hypnotizing,  either  immediately  or  at  any 
future  time. 

4.  That  the  patient  is  not  desired  to  surrender  his 
will,  but,  on  the  contrary,  is  asked  to  exercise  it  in  co- 
operation with  the  physician. 

5.  That  he  is  not  expected  to  lose  consciousness,  for 


46  PSYCHOTHERAPEUTICS 

the  lighter  degrees  of  hypnosis  are  sufficient  for  the  ac- 
complishment of  remedial  results  in  all  but  a  minority  of 
cases. 

6.  That  the  word  "  sleep "  in  this  connection  is  a 
term  of  convenience,  and  means  only  that  early  stage  of 
sleep  that  is  consistent  with  consciousness:  a  transitional 
stage  which  any  one  who  has  analyzed  his  sensations  has 
recognized  as  a  brief  period  immediately  preceding  the 
unconsciousness  of  slumber,  when  by  an  effort  he  can 
become  wide-awake,  or  by  lying  still  and  guarding  his 
mind  against  exciting  thoughts  can  insure  speedy  and 
perfect  sleep. 

7.  That  there  will  be  nothing  unpleasant  in  the  process 
—  no  shock,  no  electric-like  thrill,  no  startling  sensation ; 
but  that,  if  the  attempt  is  successful,  he  will  experience  a 
feeling  as  if  tension  was  relaxed,  a  mental  and  physical 
calm,  a  soothing  drowsiness. 

8.  That  he  must  not  be  discouraged  by  complete  fail- 
ure at  the  first  attempt,  as  it  often  happens  that  the 
excitement,  incident  to  the  novelty  of  the  situation,  de- 
feats the  efforts  of  both  parties ;  and  that,  when  he  per- 
ceives, as  he  will  from  observing  the  process  pursued,  that 
there  is  nothing  ungentle  or  in  any  way  objectionable 
about  it,  there  will  probably  be  no  difficulty  in  achieving 
success. 

9.  That  the  suggestions  will  be  made  more  emphat- 
ically than  will  seem  to  him  necessary ;  for  example,  if  a 
night's  sleep  is  desired,  it  will  be  suggested  that  he  will 
get  twelve  hours,  this  being  on  the  principle  followed  by 
a  marksman  in  putting  up  his  sight  for  a  long  shot.  If 
the  barrel  of  the  weapon  is  directed  exactly  at  the  bull's- 
eye,  the  force  of  gravity  will  draw  the  projectile  down- 
ward, and  the  mark  will  be  hit  below  the  center,  if  at  all. 
So,  too,  allowance  must  be  made  for  the  downward 
deflection  of  a  suggestion  in  an  inveterate  or  otherwise 


VALUE  OF  HYPNOTIC  SUGGESTION        47 

diificult  case.  As  the  sight  of  the  rifle  must  be  raised  so 
that  the  barrel  is  aimed  above  the  mark,  so  the  suggestion 
must  be  exaggerated,  must  be  aimed  high,  in  order  to 
reach  the  desired  point. 

10.  That  the  patient  must  not  contradict  or  resist, 
and  must  not  try  to  open  his  eyes  until  permission  is 
given  him. 

The  patient,  thus  instructed,  then  lies  down  on  a  couch, 
or  seats  himself  in  a  lounging  chair,  in  which  he  has  a 
comfortable  rest  for  his  head.  He  is  told  to  concentrate 
his  attention  upon  sleep,  to  try  to  go  to  sleep;  and,  to 
assist  him  in  this  effort  by  preventing  his  taking  in  dis- 
tracting ideas  through  his  eyes,  as  they  wander  around 
the  room  and  see  the  pictures,  books,  and  furniture,  he 
is  asked  to  fix  his  gaze  upon  some  indifferent  object,  as, 
for  example,  the  finger  of  the  physician,  which  is  held 
a  foot  or  so  from  the  face  of  the  patient.  He  is  in- 
structed not  to  try  to  keep  his  eyes  open,  and  not  to  close 
them  voluntarily,  but  merely  to  let  the  lids  go  as  they 
will.  The  physician  places  his  free  hand  upon  the  fore- 
!  head  of  the  patient,  and,  by  a  continuous  stream  of  quiet, 
!  monotonous  talk,  encourages  the  patient  in  his  effort  to 
go  to  sleep.  For  example,  he  says,  "  Try  to  sleep,  think 
of  nothing  but  sleep,  keep  your  thoughts  fixed  upon  go- 
ing to  sleep.  Your  lids  are  heavy,  they  are  drooping, 
you  are  going  to  sleep.  Every  moment  you  are  getting 
more  drowsy ;  you  feel  the  sleep  stealing  over  you.  The 
lids  are  closing;  you  are  almost  asleep.  Now  the  eyes 
have  closed;  you  have  gone  to  sleep."  Meantime  a  lit- 
tle pressure  has  been  made  upon  the  brows ;  and,  when 
the  lids  slip  down  and  cover  the  eyes,  they  are  gently 
stroked.  The  hand  is  kept  upon  the  forehead,  and  the 
•  physician  enforces  his  assurances  by  some  such  words  as 
these :  "  You  are  asleep,  though  you  have  not  lost  con- 
sciousness.    You  hear  my  voice,  the  sounds  in  the  house, 


48  PSYCHOTHERAPEUTICS 

the  noises  in  the  street  —  and  yet  you  are  asleep.  You 
feel  the  sleep  all  through  you  —  head,  trunk,  and  limbs 
are  all  heavy  with  sleep.  Your  nerves  are  all  relaxed, 
there  is  no  tension  anywhere,  3^ou  are  perfectly  tran- 
quilized.  You  will  not  move  a  muscle,  except  to  breathe, 
until  I  bid  you  wake." 

This  process  may  take  a  minute,  or  it  may  occupy  a 
quarter  hour;  but  when  it  is  completed  the  patient  is 
ready  for  the  remedial  suggestions  —  the  soil  is  pre- 
pared for  the  seed.  Then  the  physician  makes  the  nec- 
essary suggestions,  speaking  them  plainly,  putting  them 
strongly,  repeating  them,  emphasizing  them  in  the  most 
positive  and  insistent  way.  Generally  he  cannot  tell  how 
much  effect  has  been  produced;  but  something  can  be 
judged  by  the  degree  of  quietude  of  the  patient.  If  he 
is  perfectly  still,  the  probability  is  that  all  is  working- 
well;  but  certain  limited  movements  are  not  inconsistent 
with  fine  success.  A  constant  quivering  of  the  lids  is 
sometimes  observed  in  the  profoundest  stage  of  hyp- 
nosis; but  swallowing  commonly  indicates  that  only  a 
slight  degree  has  been  reached. 

Having  finished  the  remedial  suggestions,  others  are 
made  to  the  effect  that  the  hypnotic  state  can  be  induced 
more  readily  at  each  subsequent  session,  that  the  patient 
can  be  hypnotized  whenever  he  wishes  it,  and  particularly, 
that  he  can  never  be  hypnotized  by  anybody  without  giv- 
ing his  entire  consent.  In  this  way  the  patient  is  locked 
against  the  attempts  of  designing  hypnotizers,  and  may 
successfully  defy  any  efforts  to  control  him  in  this  man- 
ner. 

All  of  the  suggestions  appropriate  to  the  case  having 
been  made,  the  patient  is  allowed  to  remain  quiet  for  a 
longer  or  shorter  time,  according  to  the  seriousness  of' 
the  condition  —  a  few  minutes  or  more  than  half  an  hour; 
and  the  effect  is  deepened  by  a  gentle  though  emphatic 


VALUE  OF  HYPNOTIC  SUGGESTION        49 

repetition  of  the  suggestions.  When  the  time  for  rous- 
ing the  patient  comes  the  physician  says,  "  You  may 
wake  now."  Sometimes  the  awakening  will  be  prompt, 
sometimes  slow  and  reluctant,  the  latter  being  more 
likely  when  the  hypnosis  has  been  profound.  If  no  per- 
mission to  wake  were  given,  the  hypnotic  condition  would 
gradually  disappear,  and  the  patient  would  rouse  him- 
self as  from  ordinary  sleep. 

This  method  need  not  be  followed  in  detail;  indeed, 
every  hypnotizer  develops  his'  individual  procedure,  and 
finds  his  own  the  best  for  his  purposes.  But  there  are 
common  features  in  all  of  them,  the  essentials  —  quietude, 
confidence,  gentleness,  discreet  sympathy,  intelligent  ap- 
preciation —  are  practiced  in  various  ways. 

After  a  very  few  successful  sessions  it  becomes  unnec- 
essary for  the  patient  to  begin  the  process  with  open 
eyes ;  he  is  instructed  to  close  them  at  the  first,  and  the 
physician  gently  strokes  the  forehead  and  then  the  eye- 
lids, speaking  words  which  encourage  the  patient  to 
sleep,  and  in  a  few  moments  hypnosis  is  effected.  JVIore 
than  this,  even,  in  the  case  of  some  peculiarly  susceptible 
persons,  the  spoken  command  is  sufficient  for  the  induc- 
tion of  the  desired  condition. 

In  chronic  cases  it  is  generally  necessary  to  have  many 
sessions  with  the  patient,  and  speedier  results  are  at- 
tained, if  the  intervals  are  short.  This  method  of  treat- 
ment is  comparable  with  that  by  medicines  —  the  doses 
must  be  given  frequently  in  order  to  keep  the  system 
impressed,  as  otherwise  the  effect  of  one  wears  off  before 
another  is  administered. 

Much  time,  great  persistency,  vast  patience,  abundant 

good  nature  and  tact  are  needed  in  the  inveterate  cases. 

'I  Perseverance  in  attempts  to  hypnotize  will  sometimes  be 

I  rewarded  with  brilliant  results,  even  though  many  early 

I  trials  have  utterly  failed. 

i 
i 


50  PSYCHOTHERAPEUTICS 

Having  discussed  the  nature  of  hypnotism,  and  de- 
scribed the  methods  of  its  induction,  we  now  come  to  the 
consideration  of  the  conditions  in  which  it  can  be  ad- 
vantageously employed, 

2.       CONDITIONS    IN    WHICH    HYPNOTIC    SUGGESTION    IS 
VALUABLE 

Some  authorities  think  that  it  is  unscientific  to  separate 
functional  and  organic  diseases,  that  there  is  no  perver- 
sion of  action  independent  of  an  alteration  in  structure. 
And  yet,  a  practical  discrimination  may  properly  be  made 
without  offending  pathologic  proprieties;  and  I  trust 
that,  for  convenience,  it  is  permissible  for  me  to  employ, 
the  terms  in  their  ordinary  signification.  Assuming, 
then,  your  indulgent  forbearance,  it  may  be  said  that, 
in  a  general  way,  hypnotic  suggestion  finds  its  field  in 
the  domain  of  functional  diseases  of  the  nervous  system. 
It  may  be  used  advantageously  in  relieving  some  of  the 
sufferings  incident  to  organic  diseases ;  but  in  these  cases 
it  is  only  palliative  and  not  curative.  It  is  not  claimed 
that  all  patients  afflicted  with  such  disorders  as  usually 
yield  to  suggestion  will  be  helped  by  this  treatment;  but 
in  this  respect,  as  in  others,  the  remedy  resembles  thera- 
peutic agencies  of  physical  character.  It  is  not  reason- 
able to  look  for  universal  success  with  any  agent,  or  to 
expect  that  every  patient  will  respond  to  any  treatment 
as  does  the  average  one.  \  The  ailments  in  which  hyp- 
nosis is  of  the  most  conspicuous  value  are  those  charac- 
terized by  pain,  insomnia,  abnormal  nervous  irritability, 
depression  of  spirits,  phobias,  obsessions,  neurasthenia, 
moral  obliquity,  spasm,  nausea,  sexual  perversions,  and 
drug  habits.  The  cases  which  will  be  cited  in  illustration 
occurred  in  my  own  practice,  and  are  selected  almost  at 
random   from   a   vast   number.     The   reports   are   neces- 


I 


VALUE  OF  HYPNOTIC  SUGGESTION        51 

sarily  limited  to  the  essential  features  in  order  to  keep 
this  chapter  within  reasonable  bounds. 

Pain.  A  man  of  45  years  of  age  had  been  operated 
on  twice  for  trifacial  neuralgia.  After  each  operation 
he  had  experienced  a  year  of  comfort,  and  then  the  trou- 
ble returned  violently.  The  removal  of  the  ganglion  was 
all  that  surgery  offered  at  that  time,  and  from  this  he 
shrank  on  account  of  the  danger  to  life ;  but  he  was  will- 
ing to  try  hypnotism.  When  he  presented  himself  in 
my  office,  and  tried  to  answer  a  question,  the  effort  threw 
the  muscles  of  one  side  of  his  face  into  such  a  spasm,  at- 
tended evidently  with  extreme  pain,  that  he  motioned  to 
his  wife  to  speak  for  him.  His  diet  was  restricted  to 
liquids,  because  chewing  meant  agony ;  and  he  was  com- 
pelled to  almost  complete  silence,  because  of  the  direful 
penalty  of  speech.  He  had  a  treatment  twice  daily  for 
ten  days.  From  the  first  day  he  was  measurably  re- 
lieved, and  he  had  no  pain  after  the  fourth  day.  His 
wife  went  home  at  the  end  of  a  week,  as  she  was  no  longer 
needed  as  nurse  and  interpreter;  and  he  followed  on  the 
tenth  day,  declaring  that  there  was  no  need  of  remaining, 
as  he  was  perfectly  well,  and  he  could  return  at  any  time 
if  his  trouble  came  back.  His  abandonment  of  treat- 
ment was  against  my  judgment  and  advice,  for  the  case 
was  too  chronic  and  severe  to  justify  the  expectation 
that  it  could  be  permanently  relieved  in  so  brief  a  time ; 
but  he  never  returned,  or  reported  in  any  way.  But 
even  supposing  that  there  was  not  a  cure,  the  effect  of 
the  treatment  illustrates  the  availability  of  the  remedy 
and  its  advantages  over  physical  anodynes,  which,  in 
producing  an  equal  effect,  would  almost  certainly  estab- 
lish a  drug  habit. 

Insomnia.  A  great  affliction,  prolonged  overwork, 
and  anxiety  had  so  affected  a  man  of  35  years,  that  his 
capacity    for    sleep    was    seriously    reduced.     For    three 


52  PSYCHOTHERAPEUTICS 

months  he  had  slept  only  two  or  three  hours  in  the  twenty- 
four,  and  not  only  felt  ill,  but  looked  haggard  and  worn. 
A  single  hypnotic  treatment  refreshed  him  greatly.  He 
was  instructed  to  come  daily  for  a  while,  as  the  case  was 
chronic  and  severe;  but  a  month  went  by  without  my 
seeing  him.  Then  at  a  chance  meeting  he  was  asked  to 
give  an  account  of  himself  —  why  he  had  not  come  often, 
as  he  had  promised.  He  joyously  replied,  "What's  the 
good  of  going  to  a  doctor  when  one  is  perfectly  well.'' 
I  slept  like  a  log  all  that  night,  and  I've  slept  like  a  log 
every  night  since."  Many  years  have  passed,  and  he  has 
had  no  recurrence  of  insomnia. 

Nervous  Irritability.  A  young  matron  applied  for  re- 
lief of  pronounced  hyperesthesia.  Her  sensibilities  were 
constantly  on  edge.  The  slightest  sound,  like  that  at- 
tending the  lighting  of  a  gas  jet,  if  it  came  as  a  sur- 
prise, would  set  her  nerves  aquiver  for  an  hour.  In 
railway  travel  she  always  felt  obliged  to  take  the  most 
remote  available  seat  in  the  last  car  of  the  train  in  order 
to  be  as  far  away  as  possible  from  the  noise  of  the  bell 
and  the  whistle  of  the  locomotive.  Life  was  a  series  of 
alarms  and  distresses.  The  first  attempt  at  hypnosis 
was  an  utter  failure  —  the  patient  was  wrought  up  to 
the  highest  pitch  of  excitement,  and  therefore  could  not 
concentrate  her  attention  in  the  needed  direction.  She 
was  in  despair,  feeling  certain  that  her  last  hope  of  re- 
lief had  vanished,  and  no  encouraging  assurances  had  any 
effect.  Two  days  afterward  a  second  visit  was  made. 
The  patient  was  in  tears,  mourning  over  the  assumed  im- 
possibility of  being  hypnotized.  While  she  was  in  that 
state  of  mind  it  was  plainly  useless  to  attempt  hypnosis, 
so  the  effort  was  made  to  distract  her  attention  from 
herself.  For  an  hour  nothing  was  said  about  patient 
or  sickness  or  anything  depressing,  and  the  time  was 
spent  in  the  recital  of  droll  stories  and  in  whatever  else 


i 


VALUE  OF  HYPNOTIC  SUGGESTION        53 

might  help  to  divert  the  self-centered  and  morbid  current 
of  her  thought.  At  what  seemed  a  favorable  moment 
she  was  told  to  close  her  eyes,  and  she  obeyed  instantly. 
The  lids  were  gently  stroked,  and  hypnotization  was  ac- 
complished in  that  moment.  Suitable  suggestions  were 
made,  and  the  cure  promptly  began,  and  was  finished  in 
a  few  weeks.  Tranquillity  succeeded  excitement,  and  life 
took  on  a  very  different  aspect. 

This  case  shows  that  primary  failure  is  no  indication 
of  ultimate  results.  Excitement  is  inimical  to  hypnosis, 
as  it  is  to  true  sleep ;  and  the  patient  should  not  only  be 
willing,  but  calm  enough  to  be  able  to  concentrate  his 
attention. 

Depression  of  Spirits,  A  man  of  30  years,  gifted,  well 
educated,  and  of  fine  character  but  moody  disposition, 
had  been  afflicted  for  many  months  with  extreme  depres- 
sion, which  he  was  utterly  unable  to  throw  off.  He  was 
not  a  good  hypnotic  subject;  but  he  was  practically  re- 
stored in  a  fortnight  of  daily  sessions.  He  became 
cheerful,  regained  interest  in  his  work,  liked  to  mingle 
with  his  friends,  and  now,  after  many  years,  is  in  full 
enjoyment  of  life. 

Fear  of  Travel  on  the  Water.  A  gentleman  whose 
occupation  occasionally  required  him  to  make  little  jour- 
neys to  the  islands  in  the  harbor  had  constitutionally  so 
great  a  dread  of  water-travel  that  sometimes  he  would 
leave  the  steamboat  just  as  it  was  about  to  start,  aban- 
doning the  projected  trip,  even  though  he  appreciated 
the  urgency  of  his  business,  which  always  involved  the  in- 
terests of  others  as  well  as  his  own.  After  a  few  hyp- 
notic sessions  he  was  able  to  make  excursions  on  the  boats, 
not  only  without  mental  disturbance,  but  even  with  some 
enjoyment. 

Extreme  Timidity.  A  lady  in  early  middle  life  gave 
this  account  of  her  case :  "  Before  my  marriage  I  was  a 


L 


54  PSYCHOTHERAPEUTICS  I 

teacher,  and  experienced  no  trouble  in  addressing  a  room- 
ful of  people  whenever  my  work  required  it.  But  for 
seventeen  years  I  have  never  appeared  before  an  audi- 
ence. To-morrow  afternoon  I  am  announced  to  read  a 
paper  before  one  of  the  large  clubs  of  women,  and  I  am 
frightened  almost  to  death  at  the  thought.  My  paper 
is  a  good  one,  and  I  am  not  at  all  afraid  that  it  will  not 
be  satisfactory ;  but  when  I  try  to  read  it  aloud  at  home 
and  entirely  alone,  I  break  down;  I  cannot  help  seeing 
that  critical  audience,  and  the  thought  of  it  scares  me  so 
that  I  have  to  stop.  Can  you  not  hypnotize  my  terror; 
out  of  me,  and  put  courage  in  its  place.''  "  She  was  an 
entire  stranger  to  me,  and  the  prospect  for  success  was 
not  flattering.  Besides,  my  time  was  so  engaged  that  it 
was  impracticable  to  make  an  appointment  before  the 
next  noon.  Then,  only  two  hours  before  the  meeting  at 
which  she  was  to  perform,  she  received  the  hypnotic  sug- 
gestion which  she  desired.  The  next  day  she  called  to 
report.  Her  face  was  radiant,  and  she  gave  an  enthusias- 
tic account  of  herself,  saying,  "  I  had  no  fear,  no  diffi- 
culty whatever  in  reading.  A  lot  of  the  women  were 
moved  to  tears,  and  when  I  was  through  my  friends 
thronged  around  me  with  their  congratulations  anc 
praised  not  only  my  essay  but  the  way  in  which  I  read  it. 
But  I  told  them  that  all  the  credit  for  that  should  be 
given  to  hypnotism."  As  her  name  has  often  appeared 
in  connection  with  public  performances  since  then,  it  is 
fair  to  suppose  that  she  has  had  no  further  difficulty. 

This  case  may  strike  some  as  trivial,  and  so  it  is  as 
compared  with  many  or  most  of  those  with  which  we  have 
to  deal.  But  it  does  not  seem  to  me  unworthy  of  the 
efforts  of  a  physician.  The  slight  ailments  need  wise 
treatment,  and  their  correction  may  prevent  serious  ill- 
ness, may  even  save  life.  A  disturbance  such  as  this 
woman  had  may  easily  enough  be  the  initial  step  in  a 


VALUE  OF  HYPNOTIC  SUGGESTION        55 

series  that  leads  to  an  asylum;  but  being  corrected,  ob- 
stacles are  removed  from  the  path  to  happy  and  success- 
ful endeavor. 

Obsession.  A  young  matron  from  her  earliest  recollec- 
tion had  been  in  constant  dread  of  assassination,  but  had 
never  mentioned  the  horror  until  she  revealed  it  to  me. 
Even  then  she  would  not  have  spoken  of  it  but  that  she 
had  been  relieved  of  neuralgia  by  hypnotic  suggestion, 
and  hoped  that  her  greater  trouble  could  be  dissipated 
by  the  same  means.  She  was  afraid  of  the  dark,  even 
when  she  had  a  companion,  and  she  never  allowed  herself 
to  be  left  in  the  house  alone.  Half  a  dozen  treatments 
cured  her  completely. 

Neurasthenia,  A  lady  of  43  years  for  a  whole  decade 
had  been  in  a  condition  of  nervous  prostration,  with 
marked  digestive  disturbances.  She  was  under  treat- 
ment during  the  whole  time,  but  had  received  no  benefit. 
She  was  advised  to  try  the  effect  of  hypnotic  suggestion 
by  a  physician  who  had  declared  to  me  with  great  positive- 
ness  that  hypnotism  was  justifiable  only  in  absolutely 
hopeless  cases,  in  which  desperate  means  could  be  sanc- 
tioned. After  a  prolonged  examination  the  conclusion 
was  reached  that  no  organ  was  appreciably  diseased. 
She  was  given  treatment  every  day  for  a  month,  but 
long  before  that  time  had  elapsed  she  was  practically 
well.  Her  distresses  were  all  banished,  her  feebleness  dis- 
appeared, her  digestion  was  restored,  and  her  spirits  be- 
came buoyant. 

Moral  Obliquity.  A  lady  applied  in  deep  distress  of 
mind  concerning  her  ten-year-old  son,  a  strong,  healthy, 
genial,  little  fellow,  who  had  no  interest  in  his  school  du- 
ties, habitually  played  truant,  and  lied  in  the  most  aban- 
doned manner.  His  nature  was  very  affectionate,  and  he 
was  very  fond  of  his  mother;  but  she  had  exhausted  her 
means  of  influencing  him  without  avail.     She  consented 


66  PSYCHOTHERAPEUTICS 

to  have  hypnotism  tried  on  him.  In  three  weeks  his  par- 
ents declared  that  he  was  a  different  boy.  He  attended 
school  regularly,  took  good  rank  in  his  studies,  and  was 
proud  of  it,  and  his  word  could  be  relied  upon  implicitly. 

Asthma.  An  old  lady  who  had  suffered  from  asthma 
for  many  years  and  found  no  relief  beyond  slight  pallia- 
tion, sent  for  me  when  she  was  having  a  severe  attack. 
She  had  never  been  hypnotized,  and  her  orthopnea  for- 
bade her  lying  down  or  even  reclining,  but  she  could  en- 
dure for  a  little  while  a  slight  inclination  backward,  so 
that  the  head  rested  against  a  pillow.  In  this  position 
she  was  quickly  hypnotized,  and  was  wholly  relieved  in 
a  few  minutes. 

Seasickness.  A  young  lady  who  had  been  across  the 
Atlantic  several  times,  and  regularly  suffered  nausea 
marina,  appealed  to  me  for  prophylactic  treatment.  She 
had  deferred  the  matter  until  a  few  days  before  her  voy- 
age, and  the  attention  which  it  was  possible  to  give  her 
seemed  altogether  inadequate,  but  the  event  was  happy. 
She  was  not  at  all  disturbed  during  the  journey,  and  took 
her  meals  regularly  with  enjoyment,  all  of  which  was  the 
more  remarkable  as  her  room-mate  was  violently  seasick 
every  day  of  the  voyage,  and  depended  upon  the  ministra- 
tions of  my  patient  constantly. 

Sexual  Perversion.  Schrenck-Notzing  says  that  the 
grossest  sexual  aberrations,  even  when  they  are  deeply 
rooted  and  have  changed  the  entire  personality,  are  fre- 
quently cured  by  hypnotic  suggestion.  Krafft-Ebing,  in 
his  Psychopathia  Sexualis,  seems  to  depend  entirely  upon 
this  remedy  in  the  cases  of  which  he  speaks.  It  has  not 
been  my  fortune  to  have  as  a  patient  a  person  afflicted 
with  any  of  these  maladies.  But  a  case  was  sent  me  by 
a  friend,  a  specialist  in  neurology,  who  was  unable  to  help 
the  patient,  and,  although  thinking  lightly  of  hypnotism, 
desired  me  to  try  it  in  this  case.     The  patient  was  a  med- 


VALUE  OF  HYPNOTIC  SUGGESTION        5l 

ical  student,  a  young  man  of  neurasthenic  tendency,  who 
was  hyperesthetic  sexually,  and  was  troubled  especially 
with  priapism.  He  was  hypnotized  several  times  with 
acknowledged  benefit,  but  ceased  his  visits  before  being 
discharged  as  cured.  One  day  my  neurologic  colleague 
called  on  me  and  reported  that  the  patient  was  apprehen- 
sive that  the  treatment  had  been  carried  too  far ;  not  only 
was  he  relieved  of  his  priapism  and  other  evidences  of  his 
sexual  over-sensitiveness,  but  he  had  positive  sexual 
apathy.  Without  difficulty  the  normal  equilibrium  was 
found  and  established. 

Drug  Addictions.  An  apothecary,  about  30  years  of 
age,  had  the  alcohol  habit.  He  did  not  drink  intoxicants 
every  day,  but  once  in  a  few  weeks  he  drank  persistently 
until  his  stomach  revolted,  and  then  he  was  abstinent  un- 
til the  furore  for  alcohol  seized  him  again.  His  neces- 
sities prohibited  abandonment  of  his  work,  and  his  per- 
sistence in  it  kept  him  constantly  in  an  atmosphere  of 
temptation.  No  encouragement  to  expect  a  cure  under 
these  circumstances  was  given  him,  but  his  urgent  plead- 
ing induced  me  to  try  the  effect  of  hypnotic  suggestion. 
After  twenty  sessions  the  treatment  was  given  up  on  ac- 
count of  my  absence  from  town  for  nearly  two  months ; 
and  while  the  signs  were  hopeful,  it  was  highly  improb- 
able that  he  would  not  relapse  into  his  wretched  slavery. 
But  he  did  not,  and  years  afterward  he  remained  entirely 
cured. 

3.       CORRECTION     OF     MISCONCEPTIONS    CONCERNING 
HYPNOTISM 

There  is  a  multitude  of  errors  concerning  hypnotism, 
which  are  almost  as  prevalent  among  physicians  as  in  the 
non-medical  population,  and  a  number  of  these  will  be 
stated  and  corrected. 


56  PSYCHOTHERAPEUTICS 

It  is  commonly  supposed  that  a  person  must  lose  con- 
sciousness in  the  process.  In  most  cases  the  patient  re- 
tains consciousness  perfectly.  For  the  production  of 
some  results  the  deepest  stage  of  the  hypnotic  condition 
is  requisite;  but  for  the  ordinary  therapeutic  effects  it  is 
by  no  means  necessary.  Brilliant  cures  are  sometimes 
achieved  with  patients  who  are  hardly  made  drowsy  by 
being  hypnotized. 

It  is  a  prevalent  belief  that  only  the  weak-minded,  or, 
at  best,  the  hysteric,  are  amenable  to  hypnotic  sugges- 
tion. Nothing  could  be  farther  from  the  truth.  The 
experienced  hypnotizer  dislikes  to  deal  with  either  of 
these  classes  of  patients ;  he  would  rather  for  every  rea- 
son have  strong  men  with  cultivated  minds  and  disciplined 
wills.  The  physician  who  uses  only  physical  therapeutic 
means  prefers  the  well-balanced,  sensible,  intelligent  for 
patients,  and  so  does  the  one  who  employs  psychic  means, 
and  for  the  same  reasons.  The  hypnotizer  asks  his  pa- 
tient to  exert  his  will  in  a  specified  direction ;  he  wants  the 
intelligent  co-operation  of  the  patient,  and  this  require- 
ment is  most  difficult  for  the  feeble-minded,  the  untrained, 
the  heedless  to  meet. 

Another  mistaken  notion  is  that  only  a  minority  of  per- 
sons can  be  hypnotized.  This  is  true  only  if  one  has  in 
mind  the  idea  that,  in  order  to  be  hypnotized,  one  must 
lose  consciousness  —  which  has  already  been  declared  to 
be  an  error.  The  great  majority  of  people  can  be  hyp- 
notized to  an  extent  quite  sufficient  to  make  them  suscep- 
tible to  remedial  suggestions. 

A  misconception  which  it  is  very  difficult  to  displace 
ascribes  to  the  hypnotizer  a  peculiar  and  rare  natural  en- 
dowment. That  some  men  are  better  hypnotizers  than 
otKers  Is  unquestionably  true,  just  as  some  men  are  more 
capable  than  others  in  any  line  of  activity.  He  who  has 
a  strong  and  healthy  physical  organism,  a  powerful  mind, 


VALUE  OF  HYPNOTIC  SUGGESTION        59 

and,  perhaps  best  of  all,  an  engaging  presence,  has  ele- 
ments that  make  for  success  in  any  affairs  where  man 
meets  man ;  and,  of  course,  such  a  one  gets  the  best  re- 
sults with  his  medicines,  with  his  surgical  operations,  with 
his  electrical  applications.  Why  should  he  not  do  better 
than  most  others  in  the  use  of  suggestion,  hypnotic  or 
non-hypnotic?  But  while  this  type  is  the  highest,  there 
are  others  who,  while  not  quite  or  nearly  as  well  endowed, 
are  yet  capable  of  excellent  work ;  and  as  they  will  pass 
muster  in  the  other  styles  of  therapeusis,  so,  too,  they 
will  succeed  in  hypnosis.  Any  man  who  has  the  attributes 
which  every  medical  practitioner  should  possess  can  prac- 
tice hypnotism.  But  he  must  believe  in  it,  and  he  must 
declare  his  belief  by  the  confidence  of  his  bearing.  Self- 
;  distrust,  timidity,  uncertainty  in  the  physician  inevitably 
beget  reluctance,  fear,  and  antagonism  in  the  patient, 
whatever  the  former  undertakes  to  do,  and  whatever  the 
method  by  which  he  essays  to  do  it. 

A  common  fallacy  ascribes  whatever  result  is  experi- 
enced to  a  mysterious,  subtile  emanation  from  the  physi- 
cian which  enters  and  pervades  the  system  of  the  patient. 
This  error  is  partly  due  to  the  persistence  of  a  theory 
i which  was  upset  long  ago;  and  partly,  doubtless,  to  the 
j  likeness   which  is   popularly   thought   to   obtain  between 
I  hypnotism  and  electricity.     The  real  explanation,  is  sug- 
gestion, pure  and  simple. 

A  frequent  objection  is  that,  in  the  hands  of  an  un- 

I  scrupulous  person,  great  wrong  may  be  perpetrated  by 

j  hypnosis,  and  therefore  it  should  not  be  used.     The  same 

j  line  of  argument  would  lead  us  to  abandon  treatment  by 

i  medicines,   because    it    must   be    admitted    that    patients 

have  been  killed  by  drugs  administered  by  physicians,  and 

to  give  up  cutting  operations  in  surgery,  because  many 

I  persons  have  died  on  account  of  these  procedures.     That 

there  are  scoundrels  and  incompetents  in  the  medical  pro- 


60  PSYCHOTHERAPEUTICS 

fesslon,  as  in  all  others,  is  a  lamentable  fact;  but  they 
constitute  but  a  small  minority,  and  the  danger  of  their 
doing  harm,  maliciously  or  innocently,  by  employing 
hypnotism  is  exactly  on  a  plane  with  the  peril  which 
attends  their  practice  in  any  other  line.  Every  real 
authority  on  modern  hypnotism  says  emphatically  that  a 
suggestion  that  offends  the  moral  sense  of  the  person 
hypnotized  is  either  disregarded,  or  has  the  effect  of 
rousing  the  subject  immediately.  If  it  were  practicable 
to  incite  to  criminal  acts  through  the  agency  of  hypnotic 
suggestion,  there  would  be  no  lack  of  examples  of  this 
fact;  but  in  many  years  of  observation  not  an  authentic 
case  of  the  kind  has  come  to  my  knowledge.  The  possi- 
bilities of  such  a  method  in  the  hands  of  a  skillful  ro- 
mancer are  too  obvious  to  escape  the  attention  of  novel- 
ists, and  we  know  that  thrilling  tales  of  absorbing  in- 
terest have  been  pivoted  on  this  supposition ;  but  we  never 
encounter  such  occurrences  in  actual  life,  and  we  may 
confidently  disabuse  our  minds  of  this  groundless  appre- 
hension. 

It  is  objected  that  hypnosis,  especially  if  often  re- 
peated, weakens  the  will  of  the  patient  and  makes  him 
dependent  upon  the  mind  of  the  operator.  Such  a  re- 
sult is  imaginable,  but  can  never  occur,  if  the  physician 
is  as  careful  in  using  this  agency  as  he  always  should  be 
when  administering  drugs  or  doing  surgery.  As  a  mat- 
ter of  fact  the  will  may  be  strengthened  by  hypnotic 
suggestion,  and  the  moral  vigor  increased  in  every  re- 
spect. All  of  the  cases  of  injury  from  hypnosis  of  which 
I  have  ever  heard  have  resulted  from  the  reckless  employ- 
ment of  it  for  exhibition  purposes,  mostly  by  irresponsi- 
ble mountebanks.  The  shows  conducted  by  hypnotizers 
for  the  amusement  of  popular  audiences  should  be 
sternly  repressed.  That  this  treatment  has  not  been 
their  fate  is,  in  my  opinion,  in  considerable  degree  to  be 


I 


VALUE  OF  HYPNOTIC  SUGGESTION         61 

ascribed  to  the  attitude  of  physicians.  Repeatedly  I 
have  known  doctors  to  accept  and  use  complimentary 
tickets  to  these  wretched  performances,  thus  tacitly  be- 
stowing their  professional  sanction  on  indefensible  ap- 
plications of  hypnotism,  while  at  the  same  time  they  dis- 
play a  strong  disposition  to  outlaw  a  fellow  practitioner 
who  brings  to  bear  upon  his  patients  the  altogether 
beneficent  uses  of  the  same  agency.  If  used  discreetly, 
hypnotism  does  not  induce  insanity,  does  not  weaken  the 
mind,  does  not  do  harm  in  any  direction. 

Hypnotism  should  be  used  only  by  educated  physicians, 
and  by  them  only  as  a  remedy  or  a  means  to  diagnosis. 
If  it  had  never  been  employed  outside  of  its  legitimate 
domain  there  would  be  little  or  nothing  of  the  prejudice 
against  it  which  is  constantly  encountered  in  the  com- 
munity; and  the  sufferers,  for  whom  it  has  an  easy  and 
effectual  relief,  would  eagerly  avail  themselves  of  its 
help. 

To  some  the  practice  of  hypnotism  is  objectionable, 
because  there  are  many  charlatans  who  employ  it  or  ad- 
vertise to  do  so.  Those  who  argue  thus,  to  be  consist- 
ent and  logical,  should  abandon  the  use  of  all  medicines, 
all  hygienic  measures,  everything,  indeed,  by  which  they 
try  to  affect  their  patients,  for  there  is  nothing  that  the 
quacks  do  not  exploit.  One  can  hardly  look  at  a  daily 
paper  or  a  popular  magazine  without  having  forced  upon 
his  attention  some  flamboyant  announcement  of  a  drug, 
a  method  of  exercise,  a  kind  of  battery,  a  drink,  a  food 
—  something  presented  with  an  attractive  picture  and 
an  adroitly  worded  statement,  which,  it  is  promised,  will 
positively  put  disease  to  flight,  prolong  life  to  the  ripest 
old  age,  and  supplant  misery  with  exuberant  happiness. 
But  none  of  us  are  so  disgusted  with  these  mendacious 
advertisements  that  we  think  it  necessary  to  throw  away 
the  pharmacopeia,  cease  to  recommend  physical  culture, 


62  PSYCHOTHERAPEUTICS 

give  up  electricity,  forbid  the  use  of  alimentary  remedies. 
We  continue  to  employ  whatever  means  we  think  will 
benefit  those  persons  who  honor  us  with  their  confidence 
by  seeking  our  advice  and  skill.  Why,  then,  should  we 
select  one  particular  kind  of  agent,  and  avoid  it  on  the 
ground  that  it  Is  used  by  pretenders?  The  breadth  of 
mind  which  we  like  to  believe  characterizes  our  profes- 
sion should  enable  us  to  welcome  any  agency,  whatever 
its  origin,  however  unwisely  or  dishonestly  it  is  used  by 
others,  whatever  compromising  associations  it  has  pre- 
viously had,  provided  only  that  it  will  enable  us  more 
readily,  more  agreeably,  more  perfectly,  to  diminish  suf- 
fering, prevent  disease,  or  restore  health.  Therefore, 
when  one  hears  hypnotism  likened  to  any  of  the  popular 
mind-cure  movements,  which  to  his  trained  intellect  are 
manifestly  unscientific  and  illogical,  let  him  ascribe  the 
statement  to  ignorance,  and  enter  upon  the  investiga- 
tion of  this  form  of  psychotherapy  with  confidence  that 
the  more  he  learns  about  it  the  greater  will  be  his  respect 
for  it. 

It  has  been  alleged  that  a  belief  In  the  remedial  virtues 
of  hypnotism  would  do  away  with  the  necessity  for  diag- 
nosis. Nothing  could  be  wider  of  the  mark.  The  phy- 
sician who  includes  this  agency  in  his  armamentarium 
does  not  change  his  attitude  toward  pathology,  etiology, 
or  physical  diagnosis.  He  sees,  as  plainly  as  one  can, 
that  the  first  thing  is  to  find  out  what  is  the  matter,  to 
ascertain  the  character  of  the  malady,  and  he  does  not 
use  hypnotic  means  in  treatment  unless  his  investigation 
persuades  him  that  the  trouble  Is  of  a  kind  to  which  this 
remedy  is  scientifically  applicable. 

One  of  the  commonest  criticisms  of  hypnotism  is  to 
the  effect  that  the  ailments  which  it  relieves  are  all  im- 
aginary. If  a  patient  is  said  to  have  been  freed  from 
pain,  some  astute  skeptic  asks,  "  Was  the  pain  real?  " 


I 


VALUE  OF  HYPNOTIC  SUGGESTION        63 

To  such  the  answer  should  be :  "  When  a  patient  comes 
to  you  complaining  of  pain,  do  you  distrust  his  word? 
After  he  has  taken  the  anodyne  which  you  administer, 
and  declares  to  you  that  his  pain  has  disappeared,  do 
you  question  his  veracity?  You  cannot  prove  by  the  evi- 
dence of  any  or  all  of  your  senses  that  either  statement 
was  true  or  false,  for  his  symptom  is  absolutely  sub- 
jective. But  you  do  know  your  patient,  and  have  no 
reason  to  doubt  his  truthfulness  in  this  matter  any  more 
than  in  any  other ;  and  so  you  do  not  hesitate  to  give  him 
the  remedy  that  your  experience  has  taught  you  is 
suitable  to  his  condition.  Now,  suppose  such  a  patient 
is  treated  with  hypnotic  suggestion,  and  the  suffering  is 
promptly  abolished,  is  there  any  sense,  reason,  or  fair- 
ness in  thinking  that  his  pain  was  imaginary,  and  not  as 
real  as  that  which  was  relieved  by  your  drug?  " 

It  has  been  charged  that  hypnotism  is  not  scientific ; 
but  it  is  difficult  to  perceive  upon  what  ground  this  opin- 
ion is  based.  Tested  by  any  of  the  rules  which  we  apply 
to  the  remedies  which  we  all  employ  it  is  not  found  want- 
ing; and  it  is  not  just  to  subject  it  to  severer  tests  than 
we  think  sufficient  for  all  the  others.  If  it  is  objected 
that  we  do  not  know  the  mental  mechanism  by  which  hyp- 
nosis is  induced,  it  is  fair  to  remind  the  critic  that  he 
cannot  explain  the  mechanism  of  memory,  a  fundamental 
and  comparatively  simple  intellectual  process.  If  it  is 
alleged  that  there  is  a  large  empirical  element  in  hyp- 
notic treatment,  it  is  proper  to  ask  if,  in  this  respect,  it 
is  on  a  lower  plane  than  our  usual  method  of  using  drugs. 

It  has  been  alleged  that  the  therapeutic  effects  of  hyp- 
notic suggestion  are  but  transient:  that,  if  any  benefit 
results  from  it,  in  a  short  time  the  patient  will  relapse 
into  his  former  condition.  Nobody  acquainted  with  the 
facts  could  possibly  make  this  criticism.  The  effects  of 
no  remedy,  with  which  a  comparison  can  fairly  be  made. 


64  PSYCHOTHERAPEUTICS 

are  more  enduring  than  are  those  of  hypnotic  suggestion. 

Equally  inapplicable  is  the  comment  that  groups  hyp- 
notism with  methods  of  treatment  in  which  prominence  is 
given  to  a  mystical  element,  which  appeal  to  the  supersti- 
tious, which  associate  theology  and  therapeutics,  which 
demand  faith  in  a  dogma.  The  psychology  on  which 
hypnotic  suggestion  is  based  is  as  far  removed  from  mys- 
ticism or  religion  in  any  form  as  is  physiology  —  indeed, 
it  may  be  said  to  be  physiology  applied  to  mental  proc- 
esses. The  hypnotist  is  not  spiritistic  in  any  sense  of  the 
word;  he  asks  his  patient  for  no  faith,  save  that  which 
every  physician  has  a  right  to  expect  in  any  person  who 
confides  health  and  life  and  reputation  to  his  care.  In 
treatment  by  any  method  it  is  universally  recognized  that 
confidence  in  an  expected,  or  even  hoped  for,  result  is  a 
helpful  factor.  No  well-informed  person  thftt  doubts 
that  wonderful  cures  are  sometimes  wrought  under  the 
ministrations  of  the  most  dishonest  charlatans,  as  the 
result  of  religious  exaltation,  in  consequence  of  absorb- 
ing belief  in  absolutely  senseless  doctrines ;  and  he  knows, 
too,  that  these  beneficent  effects  are  as  abundantly  mani- 
fested among  the  worshippers  of  idols  and  the  practisers 
of  obscene  and  degrading  rites  as  among  the  people  of 
his  own  creed.  That  expectation  is  desirable  in  hyp- 
notic treatment,  as  in  any  other,  must  be  manifest;  but 
in  none  is  it  less  essential.  Particularly  may  it  be  in- 
sisted that  in  hypnotism  there  is  no  occult  or  esoteric 
element,  there  is  nothing  to  conceal,  there  is  no  desire  to 
take  advantage  of  credulity,  or  to  play  upon  the  confid- 
ing nature  of  the  ignorant  and  superstitious. 

That  hypnotism  is  often  but  little  understood  by  men 
to  whom  the  profession  has  a  right  to  look  for  enlight- 
enment in  such  matters  is  frequently  demonstrated. 
Some  of  the  high  priests  of  neurology  are  the  greatest 
sinners  in  this  direction;  but  none,  probably,  have  dis- 


VALUE  OF  HYPNOTIC  SUGGESTION        65 

played  their  incompetency  and  ignorance  quite  as  con- 
spicuously as  has  Dubois,  the  author  of  a  book  on  the 
psychic  treatment  of  nervous  disorders.  This  has  been 
translated  into  English  and  has  evidently  deeply  influ- 
enced many  physicians  and  awakened  a  wholesome  interest 
in  a  certain  form  of  psychotherapy.  His  treatment  by 
persuasion  has  undoubted  merit,  though  little  novelty; 
but  it  is  pitiful  that  he  should  assume  the  attitude  which 
he  does  toward  hypnotism  —  an  attitude  which  reveals 
at  once  ignorance,  narrowness,  prejudice,  and  inconsist- 
ency. He  girds  at  hypnotism,  at  every  opportunity,  he 
holds  it  up  to  ridicule  and  contempt ;  and  yet  he  admits 
that,  on  occasion,  he  uses  it,  as  he  certainly  should  not, 
if  it  is  the  evil  thing  that  he  would  have  us  believe.  In 
doing  this  he  unconsciously  pays  it  the  highest  tribute. 
Let  me  quote  a  passage: 

"  This  is  one  of  those  exceptional  cases  where  I  would 
not  fear  to  have  recourse  to  hypnosis,  although  the  atti- 
tude of  the  wonder-worker  that  one  has  to  take  is  so 
repugnant  to  me  that  it  brings  a  blush  to  my  cheeks  when 
I  decide  to  use  it." 

"  Wonder-working "  to  him  evidently  means  rapidity 
of  effect,  for  in  another  paragraph  he  says: 

"  The  practice  of  hypnosis  has  accustomed  one  to  im- 
mediate success,  to  theatrical  effects." 

Are  we  to  refrain  from  employing  any  method  because 
its  results  are  prompt?  We  have  been  accustomed  to 
consider  speed  in  attaining  a  desired  end  a  decided  merit. 
The  motto  on  the  seal  of  this  society,  "  Curare  cito,  tuto, 
et  jucunde,"  which  we  adopt  from  the  ancient  Asclepiades, 
is  universally  acclaimed  as  the  ideal  rule  of  action;  and 
hypnotism  fulfils  all  of  these  conditions,  for  it  does  cure 
quickly,  safely,  and  pleasantly.  Apply  the  objection  to 
another  class  of  cases:  a  patient  comes  to  a  physician 
with  a  chronic  irritative  cough.     Examination  reveals  a 


[: 


\ 


66  PSYCHOTHERAPEUTICS 

relaxed  uvula  dangling  onto  the  tongue  and  constantly 
tickling  the  pharynx.  Does  anybody  advocate  the  cut- 
ting off  of  the  sixteenth  of  an  inch  a  day  for  the  sake 
of  avoiding  the  suddenness  of  cure  effected  by  complete 
ablation?  But  the  method  by  which  instant  and  perma- 
nent relief  is  afforded  is  open  to  the  criticism  of  being 
theatrical.  Dubois  objects  to  "  wonder-working,"  if  the 
quick  cure  is  brought  about  by  hypnosis,  as  if  one  ap- 
pealed to  the  thaumaturgy  of  the  ancient  magician ;  and 
yet  he  says: 

"  The  art  of  the  physician  lies  just  in  choosing  in  each 
case  the  most  rapid  and  powerful  means  of  improvement." 

Can  inconsistency  go  further?  If  his  vaunted  method 
achieves  an  immediate  result,  it  is  praiseworthy;  but,  if 
hypnotism  does  the  same  thing,  it  is  damnable. 

To  show  how  utterly  ignorant  of  the  principles  of  hyp- 

^  notic  treatment  this  author  is,  one  more  sentence  may  be 

fe^'     quoted:   "What  is  more  absurd  than  to  fall   asleep  by 

j       daylight,  when  one  has  no  need  of  sleep,  by  stupidly  3rield- 

ing  to  the  command  of  the  hypnotizer  ?  " 

It  seems  almost  incredible  that  a  physician  who  poses 
as  a  neurologist  and  a  psychotherapist,  should  not  know 
that  the  purpose  of  the  hypnotizer  in  inducing  the  sleep; 
is  solely  to  put  the  patient  into  a  more  suggestible  con-, 
dition.  When  a  man  of  the  eminence  of  Dubois  is  ca- 
pable of  so  humiliating  an  exhibition  as  this,  we  may  lookl 
with  more  charity  and  patience  upon  the  men  who  con- 
stitute the  rank  and  file  of  the  profession,  when  they,  as 
a  result  of  dense  ignorance,  declare  hypnotism  to  be  dan- 
gerous, foolish,  quackish,  fraudulent,  necromantic,  and 
altogether  unjustifiable.  1 

It  ought  to  be  unnecessary  to  say  that  the  employ- 
ment of  any  form  of  psychotherapy  is  not  incompatible 
with  the  use  of  physical  agents  of  any  description.  In 
many  cases  it  is  important  to  associate  different  kinds  of 


I 


VALUE  OF  HYPNOTIC  SUGGESTION        67 

therapeutic  agents,  which  are  not  psychic,  as  we  all  know ; 
the  case  in  which  a  psychic  method  is  desirable  makes  no 
exception.  Psychotherapy  should  be  regarded  as  an  ad- 
ditional means  of  promoting  the  welfare  of  the  patient, 
whatever  other  kind  of  treatment  has  been  instituted. 

In  this  essay  I  have  not  attempted  an  exhaustive  treat- 
ment of  my  subject,  but  I  have  tried  to  show  as  well  as 
possible  in  the  time  allowed  what  hypnotism  is,  and  what 
can  be  done  with  it  by  any  well-educated,  competent  phy- 
sician for  the  benefit  of  the  sick  and  suffering;  and, 
finally,  I  have  endeavored  to  make  it  clear  that  the  ob- 
jections to  its  use  are  not  based  upon  knowledge,  but 
upon  ignorance  and  prejudice.  The  points  touched  upon 
are  those  about  which  questions  are  most  frequently 
asked  or  adverse  criticism  made,  and  the  answers  and  ex- 
planations are  founded  upon  a  large  observation  of  the 
practical  workings  of  the  method. 

I  have  no  expectation  of  effecting  a  wholesale  conver- 
sion of  opponents  to  these  views  —  I  know  too  well  the 
ingrained  conservatism  of  our  profession  regarding  psy- 
chic remedies;  but  I  entertain  a  little  hope  that  what  I 
have  said  will  arouse  in  some  minds  an  intelligent  interest 
in  the  sub j  cct ;  and  I  am  confident  that  no  open-minded 
physician  can  look  into  it  fairly,  as  he  would  into  any 
other  therapeutic  method,  without  being  persuaded  that 
in  hypnotic  suggestion  are  possibilities  for  good,  which 
our  profession  should  no  longer  neglect. 


CHAPTER  THREE 

Simple  Explanation  and  Re-education  as  a 
Therapeutic  Method 

BY  E.  W.  TAYLOR,   M.D. 

Assistant  Professor  of  Neurology,  Harvard  Medical  School 
Chief  of  Service,  Neurological  Dept.,  Mass.  Gen.  Hospital 

TWO  difficulties  are  evident  in  the  present  aim  to 
rationalize  psychotherapeutic  procedure.  One  is 
its  supposed  simplicity  and  the  other  its  reputed 
complexity.  A  very  considerable  group  of  men  in  the 
medical  profession  apparently  considers  that  nothing 
new  has  been  discovered  within  the  past  few  years  rela- 
tive to  the  treatment  of  disease  by  mental  means.  An- 
other group  is  equally  insistent  that  the  whole  subject 
constitutes  a  special  branch  of  medicine  and  is  quite  be- 
yond the  practical  reach  of  the  general  practitioner. 
Both  of  these  positions  are  wrong.  In  the  first  place,  it 
is  apparent  that  the  investigation  of  recent  years  has  so 
far  rationalized  old  methods  that  the  physician  now  has 
in  his  hands  a  perfectly  definite  means  of  attack  against 
many  abnormal  and  distressing  conditions.  However 
widely  psychotherapeutic  measures  have  been  practised 
from  the  earliest  period  of  medicine,  the  time  has  now 
come  when  such  measures  may  be  used  with  a  degree  of 
scientific  accuracy  hitherto  unattained,  a  precisely  sim-| 
ilar  situation  to  that  prevailing  in  all  other  departments 
of  therapeutics.  The  means  of  treatment  have  always 
been  at  hand.  The  use  to  which  those  means  are  put 
constitutes  advance.  On  the  other  hand,  it  is  true  that 
the  final  solution  of  the  complex  problems  upon  which 
we  have  now  entered  is  no  doubt  far  distant,  and  the 
pioneer  work  in  this  somewhat  limitless  field  must  be  left 

68 


RE-EDUCATION  AS  A  METHOD  69 

to  a  special  student.  There  is,  however,  no  longer  a 
question  that  sufficient  facts  have  been  established  to 
render  certain  of  these  therapeutic  measures  available 
for  the  practitioner.  Here  again  the  situation  is  not 
different  from  that  of  other  departments  of  medicine. 
The  problem  of  immunity,  for  example,  remains  obscure, 
and  in  great  measure  unsolved,  but  the  practical  applica- 
tions of  this  laborious  work  are  already  in  a  measure 
available. 

It  should  in  general  be  our  aim  to  place  this  whole 
much  discussed  question  of  psychotherapeutics  on  pre- 
cisely the  same  plane  as  other  therapeutic  problems.  So 
far  as  facts  are  ascertained  and  capable  of  practical 
application,  it  is  the  manifest  duty  of  practitioners  to 
employ  such  facts  for  the  benefit  of  their  patients.  So 
far  as  facts  are  still  in  doubt  it  is  the  natural  work  of 
special  students  of  the  subject  to  bring  what  order  is 
possible  out  of  the  existing  chaos.  Our  methods  of  pro- 
cedure should  be  the  same,  so  far  as  the  character  of  the 
subject  permits,  our  results  should  be  subjected  to  the 
same  strict  scientific  judgment,  and  our  liberality  toward 
this  branch  of  therapeutics  should  be  precisely  similar 
to  that  toward  any  other  which  promises  much  for  the 
future. 

The  object  of  this  symposium,  so  for  as  I  understand 
it,  is  for  the  time  being  to  lay  aside  theoretical  consid- 
erations and  to  bring  to  the  attention  of  this  society  such 
facts  and  practical  considerations  as  the  time  at  our  dis- 
posal and  our  individual  experience  permit.  It  is  my 
purpose  in  what  I  shall  have  to  say  under  the  somewhat 
inadequate  title  selected  to  draw  attention  to  the  simplest 
and  therefore  most  widely  available  method  of  psycho- 
therapeutic procedure  and  to  attempt  to  show  how  such 
a  method  may  be  made  practically  useful  by  the  physi- 
cian in  a  degree  hitherto  not  always  attained. 


70  PSYCHOTHERAPEUTICS 

In  discussing  the  general  psychotherapeutic  problem 
with  physicians,  the  purely  practical  question  of  method 
is  almost  invariably  raised.  What  the  practitioner  needs 
and  rightly  demands  from  those  who  claim  any  special 
knowledge  of  the  subject  are  directions  as  to  treatment 
of  individual  patients.  The  evident  difficulty  heretofore 
in  treating  even  the  simple  neuroses  has  been  the  failure 
on  the  part  of  physicians  to  recognize  clearly  that  such 
neuroses  very  frequently  have  a  mental  cause  in  the  life 
of  the  individual  precisely  as  a  murmur  over  the  heart 
area,  for  example,  has  a  physical  cause  in  the  life  of  the 
individual.  Our  first  object,  as  practitioners,  is  the  de- 
termination so  far  as  lies  in  our  power  of  the  exact  cause 
of  the  condition  we  are  called  upon  to  treat.  In  other 
words,  a  diagnosis  is  demanded.  This  we  make  readilj^ 
enough  in  the  physical  sphere  or  admit  our  incapacity  to 
do  so.  In  the  mental  sphere,  we  too  often  make  no  at- 
tempt, however  apparent  the  cause  might  be  after  ade- 
quate investigation.  The  first  point,  therefore,  I  would 
make  is  that  we  must  be  as  conscientious  in  one  field  of 
medicine  as  in  another.  We  must  search  the  mind  of  the 
individual  for  the  source  of  his  discomfort  in  appropriate 
cases  in  exactly  the  same  spirit  in  which  we  search  his 
body  for  the  source  of  other  discomforts.  This  cer- 
tainly requires  no  special  personal  attributes  on  the  part 
of  the  physician,  and  is  surely  available  for  practition- 
ers of  no  special  education  in  this  field.  The  word  "  ex- 
planation "  used  in  the  title  describes  somewhat  inade- 
quately the  actual  procedure,  which  consists  essentially 
in  the  following  steps: 
I  First.  After  eliminating  or  properly  estimating 
physical  causes ,  the  mental  attitude  of  the  patient  to- 
ward his  ailment  should  be  carefully  determined;  in  other 
words,  a  diagnosis  should  be  made. 
5         Second.     This  is  best  accomplished  by  allowing  him  to 


RE-EDUCATION  AS  A  METHOD  71 

tell  his  complete  story  rather  than  by  a  primary  process 
of  interrogation  on  the  part  of  the  physician. 

Third.  Having  determined  the  false  point  of  view 
almost  invariably  revealed  which  has  led  up  to  the  neu- 
rosis .the  attempt  is  made  to  explain  why  such  a  series  of 
events  as  that  disclosed  would  be  likely  to  lead  to  this 
result. 

H  Fourth.  Having  impressed  the  patient  with  the  cor- 
rectness of  the  physician's  point  of  view  the  process  of 
readjustment  begins,  or,  to  use  the  more  popular  but 
possibly  too  comprehensive  term,  his  re-education. 

Fifth.  This  is  accomplished  by  pointing  out  in  a 
painstaking  way  the  correct  way  to  mental  health  through 
a  realization  on  the  part  of  the  patient  of  his  previous 
misconceptions  and  through  an  accompanying  effort  to- 
ward the  establishment  of  more  rational  mental  adjust- 
ments. 

The  method  outlined  above  is  the  simplest  possible 
psychotherapeutic  procedure.  As  in  more  complex  meth- 
ods described  by  other  writers  in  this  symposium  its  es- 
sential feature  is  the  analysis  of  the  mental  state.  Its 
value  lies  in  its  simplicity  and  in  its  appeal  to  the  reason 
through  the  medium  of  commonsense.  We  are  justified 
in  calling  it  a  method  because  it  works  in  practice,  when 
mere  unmethodical  encouragement  and  reassurance  fail. 
That  such  a  method  stripped  as  it  is  of  all  appeal  to  the 
mysterious  or  to  any  form  of  sensationalism  is  capable 
of  wide  and  legitimate  application  is  self-evident.  It  is 
also  apparent  that  it  must  often  prove  unsuccessful  in 
those  cases  in  which  the  course  of  a  developed  neurosis 
is  so  deeply  buried  in  the  past  life  of  the  individual  that 
it  cannot  be  brought  to  the  surface  by  this  simplest  and 
in  one  sense  most  superficial  of  the  analytic  methods. 

It  may  with  truth  be  said  that  no  person  is  wholly  free 
from  false  conceptions  of  his  own  mental  and  physical 


72  PSYCHOTHERAPEUTICS 

condition,  and  this  naturally  applies  to  those  who  con- 
sult physicians  in  the  most  varied  fields  of  practice.  It 
is  an  error  to  stigmatize  such  persons  forthwith  as  ab- 
normal or  neurotic  or  neurasthenic  or  psychasthenic. 
Many  of  the  common  neuroses  met  with  in  practice  rep- 
resent nothing  more  than  aberrations  of  normal  nervous 
systems  into  temporary  useless  or  detrimental  channels. 
As  a  matter  of  fact,  a  large  proportion  of  so-called  nerv- 
ous invalids  are  incapacitated  through  no  inherent  fault 
of  their  nervous  systems  as  such,  but  rather  through  the 
use  to  which  their  nervous  systems  have  been  put  by  cir- 
cumstances or  training  or  false  instruction  or  unwise  and 
superficial  medical  advice. 

Quite  apart  from  any  psychophysical  speculation  as  to 
the  relation  between  the  mind  and  the  body  which  is 
wholly  unessential  from  a  practical  standpoint,  the  clear 
recognition  of  the  predominant  mental  origin  of  the 
neuroses,  whether  or  not  they  have  accompanying  phys- 
ical manifestations  is  of  the  utmost  importance  and  un- 
questionably constitutes  the  essential  advance  of  recent 
years  in  their  intelligent  treatment.  We  have  gained 
much,  if,  for  example,  we  may  authoritatively  tell  our 
patients  that  their  apparently  disordered  nervous  symp- 
toms have  reacted  in  a  perfectly  normal  way  to  the  cir- 
cumstances in  which  they  have  been  placed,  and  to  the 
ideas  to  which  they  have  been  exposed,  and  that  their 
difficulties  have  been  due  to  the  character  of  these  ideas 
and  circumstances  rather  than  to  the  much  feared  in- 
herent weakness  of  the  nervous  system  itself.  The  func- 
tion of  the  physician  at  once  becomes  apparent.  He 
hears  the  story,  he  sees  wherein  the  individual  has  failed, 
wherein  he  has  dissipated  his  energies  in  side  issues,  or, 
in  popular  parlance,  wasted  his  opportunities.  Out  of 
this  he  recognizes  that  a  so-called  neurosis  has  devel- 
oped  which  it  becomes  his  task  to  diagnosticate  accu- 


i  RE-EDUCATION  AS  A  METHOD  73 

rately,  to  explain  in  an  understandable  way  the  steps  by 
which  he  has  arrived  at  his  diagnosis,  and  to  readjust 

I    the  patient's  mental  attitude  on  the  basis  of  this  knowl- 
edge. 

In  order  to  avoid  any  possibility  of  confusion  I  have 
used  the  word  "  explanation  "  to  describe  this  rational 
process.  It  requires  little  actual  experience  to  demon- 
strate that  in  order  to  explain  these  matters  effectively 
to  our  patients  we  must  follow  some  definite  method. 
Otherwise,  as  in  other  departments  of  endeavor,  we  shall 
simply  confuse  and  not  benefit.  It  is  furthermore  im- 
perative, with  all  the  present  day  talk  in  the  popular  press 
as  well  as  in  medical  literature  regarding  treatment  by 
mental  means,  that  we  adopt  a  definite,  commonsense  ba- 
sis of  procedure,  free  from  all  subtlety  or  demand  for 
highly  specialized  training. 

/  From  the  foregoing  discussion  I  wish  to  emphasize  the 
following  pomts:)First,  the  wide  prevalence  of  neuroses 
based  on  ignorance  rather  than  inherent  or  acquired 
weak  nervous  organization.  «lSccondly,  the  vital  impor- 
tance of  recognizing  the  normal  character  of  the  nerv- 
ous systems  in  which  these  neuroses  have  developed. 
Thirdly";  the  possibility  as  a  rational  means  of  treatment 
of  explaining  to  an  intelligent  patient  the  mechanism  of 
the  development  of  his  symptoms,  ihd  finally  the  prob- 
ability of  a  readjustment  of  his  mental  state  based  on 
this  explanation  with  the  disappearance  of  the  neurosis. 
The  analogy  of  the  mental  state  of  the  child  is  useful 
in  this  connection.  Explanation  forms  the  chief  means 
of  increasing  a  child's  mental  stability.  Fear  of  the 
dark,  to  take  a  commonplace  example,  is  not  met  on  the 
part  of  the  wise  parent  by  harsh  criticism  and  summary 
dismissal  of  the  subject,  but  rather  by  explanation  suited 
to  the  child's  comprehension  that  the  dark  in  reality  has 
no  terrors,  and  by  a  demonstration  of  the  truth  of  this 


74  PSYCHOTHERAPET  TICS 

fact.  Similar  fears  in  adult  life  are  manifestly  treated 
with  far  less  consideration;  on  the  part  of  the  patient 
there  is  a  tendency  toward  concealment  of  special  anxie- 
ties, on  the  part  of  the  physician  there  is  often  a  wholly 
unsympathetic  attitude  in  which  explanation  plays  no 
part.  The  position  of  the  adult  is,  however,  precisely 
analogous  to  that  of  the  child.  Neither  is  the  victim  of 
disease  or,  necessarily,  possesses  a  damaged  nervous  sys- 
tem. Both  are  victims  of  insufficient  knowledge  and  both 
demand  sympathetic  explanation  in  order  that  their  false 
points  of  view  may  be  corrected.  Both  are  real  and 
often  extreme  sufferers  from  conditions  which  are  not 
self-limited,  but  which  tend  to  progress  and  become  more 
complex  in  their  organization.  Our  attitude  toward 
children  has  on  the  whole  been  correct;  our  error  has 
been  the  failure  to  realize  that  wisdom  does  not  neces- 
sarily come  with  the  years. 

Examples  may  make  this  clearer.  A  patient  consults 
a  physician  in  a  highly  disturbed  nervous  state  popularly 
known  as  neurasthenic.  The  analysis  of  the  entire  situa- 
tion reveals  the  fact  that  this  patient  considers  that  he 
has  lost  his  memory.  He  has  arrived  at  this  conclusion 
because  he  finds  that  he  is  no  longer  able  to  read  at- 
tentively and  remember  what  he  has  read.  From  this  as 
a  starting  point  he  argues,  legitimately  enough  from  his 
knowledge,  as  follows:  I  cannot  remember  what  I  havo 
read ;  my  memory  must  therefore  be  weakened ;  memory 
is  a  fundamental  quality  of  the  normal  mind;  my  mind 
therefore  must  be  failing,  and  forthwith  one  of  the  com- 
monest and  most  distressing  and  incapacitating  phobias 
is  developed,  namely,  the  imminent  fear  of  insanity.  In 
such  a  commonplace  instance  as  this  it  is  clear  that  the 
patient's  mind  has  worked  out  a  rational  conclusion  from 
false  premises,  the  original  false  premise  being  that  be- 
cause he  could  not  remember  what  he  read,  therefore  his 


RE-EDUCATION  AS  A  METHOD  75 

mind  was  failing.  It  is  easy  to  set  such  a  person  right 
by  the  simple  explanation  that  his  original  difficulty  arose 
from  lack  of  concentration,  a  common  human  weakness, 
and  that  out  of  such  lack  of  concentration  the  mental 
alienation  which  he  feared  is  extremely  unlikely  to  de- 
velop. This  rational  point  of  view  is  on  the  whole  easy 
to  impress,  and  its  result  on  the  developed  neurosis  with 
its  various  accompanying  manifestations  of  sleeplessness, 
anxiety,  incapacity  for  work,  loss  of  appetite,  and  all 
the  other  phenomena  of  a  disturbed  mental  state,  forth- 
with becomes  apparent.  The  essence  of  the  benefit  in 
such  a  case  is  to  be  attributed  purely  to  a  reasonable 
explanation  of  a  series  of  events  which  the  patient  has 
himself  been  unable  to  estimate  properly. 

A  further  example  illustrative  of  the  point  of  view  I 
am  attempting  to  impress  is  the  mental  condition  ordi- 
narily associated  with  insomnia.  There  is  a  deeply 
rooted  feeling  in  the  popular  mind  that  sleep  is  an  abso- 
lute essential  to  continued  mental  health  and  conversely 
that  deprivation  of  sleep  is  a  direct  sign  of  both  physical 
and  mental  breakdown.  Assuming  this  statement  to  be 
correct  the  ordinary  person  finds  himself  in  a  state  of 
extreme  anxiety  when  for  any  reason  his  sleep  is  inter- 
fered with.  The  result  of  this  anxiety  very  naturally  is 
such  a  fixation  of  the  attention  upon  his  physical  and 
mental  condition  that  sleep  for  this  very  reason  becomes 
increasingly  difficult.  Thus,  the  ordinary  vicious  circle 
is  formed.  I  have  in  mind  a  patient,  a  middle-aged  man 
of  active  business  interests,  who  was  so  strongly  im- 
pressed with  the  idea  that  without  sleep  he  must  neces- 
sarily go  to  pieces,  that  his  life  was  becoming  a  burden 
to  himself  and  to  his  friends.  Reasoning  from  his 
premises,  he  assumed  that  inasmuch  as  sleep  was  essen- 
tial to  continued  health  and  he  was  certainly  not  having 
a  normal  amount  of  sleep,  he  could  not  continue  well. 


76  PSYCHOTHERAPEUTICS 

The  treatment  of  this  situation  stated  in  barest  outline 
was  in  the  first  place  to  explain  that  he  had  a  wrong  con- 
ception of  the  significance  of  sleep,  that  complete  phys- 
ical and  mental  rest  without  sleep  would  suffice  to  restore 
him  for  the  work  of  the  succeeding  day,  and  finally  that 
could  he  compose  himself  to  such  complete  physical  and 
mental  rest,  sleep  would  naturally  follow.  This,  as  a 
matter  of  fact,  is  what  actually  happened.  The  cause 
of  the  sleeplessness  in  this  instance  was  essentially  the 
mental  state  induced  by  the  fear  that  he  would  not  sleep. 
A  more  striking  instance  is  that  of  a  man  from  the  Prov- 
inces, also  of  middle  age,  who  for  some  six  years  had  been 
unable  to  sleep  and  had  developed  various  so-called  neu- 
rotic symptoms  as  he  supposed  in  consequence  of  this 
sleeplessness.  The  origin  of  his  difficulty  he  definitely 
attributed  to  a  single  occasion  when  he  had  more  or  less 
voluntarily  remained  awake  practically  all  night  in  an- 
ticipation of  a  very  early  morning  journey.  From  this 
simple  and  commonplace  event,  the  habit  of  sleeplessness 
apparently  was  formed,  and  from  that  time  to  this  it  has 
been  kept  alive  evidently  by  the  anxiety  which  has  devel- 
oped in  consequence  of  his  conception  of  the  necessity  of 
sleep,  precisely  similar  to  the  case  just  cited.  Here  also 
it  was  not  difficult,  after  three  or  four  interviews  in  which 
explanation  alone  was  used,  to  show  the  patient  wherein 
his  knowledge  had  been  deficient  regarding  various  physi- 
ological processes  connected  with  sleep  and  to  make  clear 
to  him  the  pernicious  part  his  faulty  mental  attitude  had 
played  in  the  development  of  his  neurosis.  The  patient 
was  easily  relieved  of  his  difficulty,  at  least  until  he  left 
Boston  to  return  home.  I  have  not  heard  from  him  since. 
It  would  be  easy  to  multiply  cases  of  this  sort,  illus- 
trative of  the  part  which  incorrect  deductions  play  in 
the  development  of  most  varied  neurotic  conditions.  The 
foregoing  instances,  however,  may  suffice  to  illustrate  in 


RE-EDUCATION  AS  A  METHOD  77 

simplest   form   the   principle   underlying  this   method   of 
psychotherapeutic  procedure. 

The  possibilities  and  limitations  of  the  method  I  have 
attempted  to  outline  may  be  summarized  but  not  detailed 
in  so  brief  a  communication  as  this.  Its  possibilities  are 
that  it  may  be  used  by  any  intelligent  physician  who 
I  realizes  its  importance;  the  personality  of  the  physician 
'  about  which  we  still  continue  to  hear  plays  a  small  part 
in  its  success.  It  requires  no  special  training,  psycho- 
logical or  otherwise,  beyond  that  which  every  educated 
physician  might  easily  acquire.  It  is  not  limited  to  the 
treatment  of  so-called  "  nervous  "  cases.  It  should,  for 
example,  be  applied  antecedent  to  surgical  operations, 
particularly  on  the  pelvic  organs  of  women.  It  is  a 
commonsense  method  of  approach  to  many  of  the  minor 
ills  and  some  of  the  major  disorders  to  which  all  per- 
sons are  exposed.  It  does  not  demand  hypnotic  pro- 
cedure, or  the  use  of  suggestion  as  that  word  is  ordi- 
narily employed.  Its  essential  basis  is  an  appeal  to 
reason  and  herein  naturally  lies  its  wide  applicability. 
Its  limitations  are  no  less  apparent.  It  will  naturally 
fail  in  the  psychoses,  in  hysterical  states  associated  with 
fundamental  disorders  of  personality,  and  in  obsessional 
conditions  of  a  high  degree  of  fixity,  matters  to  which 
no  doubt  others  taking  part  in  this  discussion  will  refer. 


CHAPTER  FOUR 

The  Treatment  of  Fatigue  States 
by  g.  a.  waterman,  m.d. 

TAKING  the  various  forms  of  the  psycho-neuroses 
as  a  group  there  is  no  one  symptom  so  frequently 
encountered  as  that  of  fatigue.  Whether  it  be 
present  early  in  the  course  of  the  disease,  and  seems  to 
be  the  soil  from  which  other  symptoms  develop,  or 
whether  it  makes  a  later  appearance  as  if  in  consequence 
of  the  struggle  against  existing  symptoms,  it  too  often 
presents  a  barrier  to  recovery  which  at  times  seems  un- 
surmountable.  Any  effort  on  the  part  of  the  patient  to 
struggle  against  this  symptom  so  increases  the  fatigue 
as  to  accentuate  other  symptoms,  and  cause  great  dis- 
comfort, while  on  the  other  hand  continued  rest  is  courted 
in  vain.  In  order  to  determine  how  this  condition  is  to 
be  met,  let  us  turn  our  attention  to  the  elements  which 
go  to  make  up  this  fatigue. 

1.       PHYSIOLOGICAL  FATIGUE 

That  the  production  of  energy  of  every  sort  Is  the  re- 
sult of  a  katabolic  process  in  the  tissue  called  into  activ- 
ity is  a  fact  too  well  established  to  require  discussion, 
but  unfortunately  fatigue  cannot  be  explained  on  the 
simple  ground  that  the  consumption  of  muscular  sub- 
stances alone  produces  exhaustion. 

In  addition  to  the  diminished  supply  of  the  substances 
in  the  muscle  necessary  for  the  production  of  energy 
which   results   from  muscular   activity,  we  have   also  to 

recognize   the   role   played  by   the    action   of  the   toxic 

78 


TREATMENT  OF  FATIGUE  STATES        79 

products  of  oxidation  accumulating  in  the  tissue.  The 
laboratory  experiment  of  stimulating  the  isolated  frog's 
muscle  until  it  can  perform  no  more  work,  and  then  flush- 
ing out  its  blood  vessels  with  normal  salt  solution  to  en- 
able it  to  again  respond  to  stimulation,  represents  the 
normal  physiological  process  constantly  going  on  in  the 
human  organism  during  its  daily  life. 

While  these  two  processes  —  the  combustion  of  sub- 
stances, and  the  local  action  of  the  products  of  katabo- 
lism  —  diminish  the  power  of  the  muscle  to  carry  on  its 
function,  the  liberation  of  the  poisonous  substances  into 
the  general  circulation  gives  rise  to  the  general  sense  of 
fatigue  in  the  individual.  This  has  been  well  shown  by 
Mosso,  who  demonstrated  that  the  introduction  of  the 
blood  of  dogs  that  had  been  tetanized  a  few  minutes,  into 
the  cerebral  circulation  of  healthy  dogs,  gave  rise  to 
the  signs  of  fatigue  (difficulty  in  breathing,  and  more 
rapid  beating  of  the  heart),  and  Mosso  believes  that  these 
noxious  products,  acting  on  the  nervous  system  through 
the  circulation,  not  only  contribute  largely  to  the  feeling 
of  fatigue,  but  also  lessen  the  power  of  the  nerve  cells 
to  carry  on  their  function. 

Parallel  to  these  manifestations  of  muscular  activity 
is  a  group  of  physiological  and  histological  changes  tak- 
ing place  in  the  central  nervous  system  as  a  result  of 
cerebral  and  reflex  activity.  Hodge  demonstrated  in 
1892  that  definite  changes  are  to  be  found  in  cerebral 
and  spinal  ganglion  cells  of  various  animals  resulting 
from  normal  activities  of  daily  life  as  well  as  from  ex- 
cessive stimulation.  He  found  that  a  comparison  of 
nerve  cells  of  animals  killed  in  the  morning  with  those  of 
similar  animals  killed  at  the  close  of  a  day  of  activity, 
showed  a  diminution  in  the  size  of  the  neuclei  with  loss 
of  the  open  reticulate  appearance,  and  shrinkage  in  cell 
protoplasm  with  vacuolation  and  lessened  staining  power. 


80  PSYCHOTHERAPEUTICS 

That  this  change  in  structure  is  associated  with  libera- 
tion of  harmful  products  has  been  shown  by  Halliburton 
in  his  lecture  on  "  The  Chemical  Side  of  Nervous  Activ- 
ity," in  which  he  maintains  that  under  normal  physio- 
logical conditions  the  injurious  choline  products  of  nerve 
katabolism  can  be  demonstrated  in  the  body,  while  in 
states  attended  with  abnormally  rapid  nerve  degenera- 
tion marked  changes  may  be  produced. 

2.       PSYCHOLOGICAL    FATIGUE 

Aside  from  these  physiological  processes  which  con- 
tribute to  make  up  what  may  be  called  physiological  fa- 
tigue, there  is  a  varying  psychological  factor  which  is 
present  in  all  of  us,  tending  to  accentuate  or  diminish 
the  degree  to  which  it  shall  be  recognized  and  admitted, 
whether  consciously  or  not.  The  power  of  music  to 
quicken  the  lagging  steps  of  tired  soldiers;  the  influence 
of  the  emotions  in  redoubling  one's  strength;  the  driving 
force  of  exhortation  or  promised  reward,  are  well-known 
examples  of  the  way  in  which  the  feelings  of  fatigue  may 
be  dispelled.  Is  it  that  the  marching  soldier  is  actually 
rendered  less  tired  by  the  music,  or  that  the  threat  or 

<;  promise  of  reward  makes  any  change  in  the  physical 
condition  of  the  individual?  Such  an  assumption  would 
be  obviously  absurd.     This  sudden  change  in  the  feeling 

^r' described  involves  what  might  be  termed  the  psycholog- 
ical element  in  the  symptom  of  fatigue.  In  the  minds  of 
all  of  us  a  feeling  of  fatigue  indicates  a  call  for  rest  on 
the  part  of  nature.     When  one  begins  to  feel  tired  his 

J  mind  becomes  impressed  with  the  fact,  and  the  continued 
^consciousness  that  this  state  exists  serves  to  intensify 
^he  sensation  to  a  greater  or  less  degree,  depending  on 
the  suggestibility  of  the  individual.  A  veritable  fatigue 
hyperesthesia  develops.  In  some  this  psychological  ele- 
ment may  play  by  far  the  greatest  part  in  the  production 


TREATMENT  OF  FATIGUE  STATES        81 

of  the  symptom,  so  that  the  slightest  muscular  activity 
produces  a  feeling  of  exhaustion  lasting  for  days,  while 
in  others,  determination  of  purpose  or  interest  in  work 
may  engender  a  disregard  or  an  anesthesia  for  the  symp- 
tom and  thus  enables  them  to  do  tremendous  amounts  of 
work  with  little  discomfort.  It  is  to  this  latter  class 
that  James  refers  in  his  "  Energies  of  Men  "  in  which 
he  describes  the  process  as  a  breaking  through  the  zone 
of  fatigue,  or  getting  one's  second  wind.  That  the 
adoption  of  this  habit  has  its  merits  to  a  certain  extent 
'n  the  former  class  is  undoubted,  but  I  am  convinced  that 
it  is  a  dangerous  recommendation  for  the  latter  class, 
which  is  naturally  the  one  to  carry  it  out  most  zealously. 

3.       PSYCHOPATHOLOGICAL   FATIGUE 

It  is  an  interesting  problem  for  solution  as  to  what 
takes  place  in  those  cases  of  pronounced  fatigue  in  neu- 
rotic individuals,  who  at  times  are  so  quickly  relieved  of 
the  symptom  by  a  suggestion,  as  well  as  in  those  who  ar« 
suddenly  overwhelmed  by  a  sense  of  exhaustion  as  a  re- 
sult of  a  nervous  shock  or  a  fright.  Surely  such  sudden 
and  decided  changes  cannot  permit  an  explanation  on 
the  grounds  of  any  of  the  physiological  causative  factors 
of  fatigue.  Is  it  not  that  a  synthesis  takes  place  in  the 
former,  and  a  dissociation  in  the  latter,  much  as  other 
manifestations  of  these  processes  may  occur  under  simi- 
lar conditions?  The  verification  of  this  hypothesis 
might  be  found  in  the  appearance  and  disappearance  of 
fatigue  encountered  in  the  alternations  of  personalities 
described  by  Prince,  Janet,  and  others. 

That  fatigue  states,  whether  physiological,  psycho- 
logical, or  psychopathological,  may  form  a  fertile  soil 
for  the  development  of  psycho-neurotic  symptoms  is  too 
often  demonstrated  to  us  to  admit  of  question.  In  the 
routine  of  daily  life,  if  one  is  assiduously  devoting  his 


82  PSYCHOTHERAPEUTICS 

energies  to  accomplishing  certain  ends,  the  rested  indi- 
vidual who  starts  the  day  presents  a  very  different  men- 
tal attitude  to  his  surroundings,  to  the  one  who  returns 
home  at  night  weary  from  his  labors.  The  one  starts 
out  fresh  and  vigorous  and  filled  with  the  joy  of  living, 
the  other  too  often  returns  with  slower  step  and  perhaps 
with  tired  or  aching  head,  irritable  to  those  about,  and 
critical  of  things  he  overlooked  so  easily  in  the  morning. 
It  requires,  however,  but  the  reconstructive  power  of 
sufiicient  nourishment  and  a  good  night's  rest  for  the 
pendulum  to  swing  back  and  establish  the  diurnal  state 
of  freshness.  Fortunate  is  he  who  can  carry  on  his  life 
from  day  to  day  unruffled  by  the  stress  of  extra  bur- 
dens or  the  worry  of  added  cares.  In  those  who  volun- 
tarily undertake  excessive  amounts  of  work,  or  who  are 
the  unfortunate  victims  of  the  "  slings  and  arrows  of 
outrageous  fortune,"  the  periods  of  recuperation  may 
not  prove  sufficient  to  maintain  the  state  of  equilibrium, 
and  a  more  or  less  prolonged  state  of  fatigue  may  result 
with  its  various  concomitant  symptoms. 

Continued  fatigue  with  insufficient  periods  of  rest  may 
develop  in  strong,  healthy  individuals  various  forms  of 
physical  and  mental  symptoms  similar  to  those  seen  in 
well-defined  neuroses  and  psychoses.  Attention  has  been 
called  to  this  by  Tissie  and  Fere,  and  it  was  well  illus- 
trated in  the  condition  developed  in  the  bicycle  riders  of 
the  six-day  race  in  Madison  Square  Gardens  a  few  years 
ago.  Various  sorts  of  delusions  and  hallucinations  were 
manifested  by  these  men  towards  the  close  of  the  race  — 
the  idea  that  spectators  were  doing  things  to  prevent 
their  winning  led  to  their  repeatedly  turning  to  escape 
imaginary  obstacles,  etc. 

The  ill  effects  of  over-fatigue  from  excessive  muscular 
exercise  are  usually  quickly  recovered  from,  but  the  con- 
ditions resulting  from  prolonged  mental  strain  and  worry 


TREATMENT  OF  FATIGUE  STATES         83 

are  more  liable  to  persist  from  the  very  nature  of  their 
cause,  in  being  more  continuous  and  unremitting.  The 
story  is  a  common  one.  One's  duties  necessitating  men- 
tal application  have  been  requiring  too  many  hours ;  they 
are  not  dropped  in  the  evening ;  sleep  is  more  difficult,  and 
the  diminished  hours  of  recuperation  lessen  the  power  of 
application;  recognition  of  this  fact  brings  worry  to  ^/ 
the  attack  to  precipitate  the  uncomfortable  feelings  of 
fatigue.  Aside  from  lassitude  and  loss  of  power  to  con- 
centrate, the  most  frequent  symptom  experienced  in  this 
state  is  a  sense  of  discomfort  in  the  head  varying  in  char- 
acter and  location.  This  engenders  the  idea  that  some- 
thing must  be  wrong  within,  and  too  frequently  suggests 
that  insanity  is  imminent,  and  gives  rise  to  overwhelming 
fear  and  constant  introspection,  with  all  its  harmful  in- 
fluences. 

Distinct  from  the  fatigue  states  of  such  etiology  which 
may  exist  as  a  simple  condition  of  weariness  and  dimin- 
ished power  of  application,  or  may  present  the  compli- 
cation of  morbid  ideas  developing  from  it,  is  the  state  / 
of  so-called  "  nervous  exhaustion  "  found  in  individuals  "^ 
with  a  neurotic  family  history.  Patients  suffering  from 
this  condition  have  often  experienced  a  series  of  nervous 
breakdowns,  and  never  seem  able  to  struggle  to  the  nor- 
mal level.  Such  individuals,  though  they  present  the 
same  symptoms  as  the  class  described  have  the  psycho- 
logical element  of  fatigue  developed  out  of  all  proportion 
to  the  physical,  and  every  attempt  at  a  departure  from 
their  life  of  rest  and  quiet  is  made  under  protest,  and 
with  the  firm  conviction  that  disaster  is  sure  to  follow. 

That  the  type  of  fatigue  brought  about  by  prolonged 
overwork  or  strain  requires  rest,  relaxation,  and  change  J 
of  surroundings,  combined  with  advice  best  adapted  to 
counteract  the  morbid  mental  state  which  may  be  present, 
is   apparent.     This   class   comprises  the  cases  which  do 


84  PSYCHOTHERAPEUTICS 

well  by  giving  up  absolutely  the  sort  of  life  which  has! 

J  absorbed  them,  and  combining  rest  with  activities  of  a- 

different   nature   which  will   afford   sufficient  interest  to 

divert  the  mind  and  prevent  reflection.  j 

The  point  must  be  recognized  and  seized,  however,' 
when  this  regime  has  played  its  part,  and  the  time  has 
/  come  for  putting  the  hand  to  the  plough  again,  for  it  is . 
all  too  easy  for  the  memory  of  a  previous  breakdown  and  1 
fear  of  its  recurrence  to  render  one  loath  to  resume  his 
former  life  again.  It  is  on  account  of  this  fear  and  hesi- 
tation that  it  is  advisable  to  keep  in  touch  with  the  pa- 
tient and  prevent  backsliding  until  he  is  well  launched 
in  his  old  life. 

The  larger  class  of  patients  so  often  descended  from 
neurotic  parents  and  presenting  a  history  of  attacks  of 
previous  nervous  breakdowns,  attempting  again  and 
again  to  take  up  the  duties  of  life,  but  never  seeming  able 
to  get  sufficient  reserve  to  carry  on  the  struggle  for  any 
prolonged  period  of  time,  require  management  of  a  dif- 
ferent sort.  Such  cases,  as  has  been  said,  represent  the 
psychological  element  of  fatigue  in  its  fullest  develop- 
ment. The  conviction  that  exhaustion  will  follow  any 
amount  of  effort,  physical  or  mental,  is  already  a  guar- 
antee that  it  will  result.  On  being  told  to  do  certain 
things  a  patient  recently  remarked,  "  Very  well,  I'll  do 
it,  but  I  know  what  will  happen,  and  you  must  take  the 
consequences."  Of  course  if  she  had  followed  orders  in 
such  a  spirit  the  result  must  have  been  as  she  determined. 

Frequently  these  patients  have  indulged  in  rest  for 
months,  or  even  years,  without  beneficial  results.  Phys- 
ically sound,  but  unable  to  assume  duties  and  responsibili- 
ties of  life,  they  form  a  group  too  often  misunderstood, 
and  classed  as  uninteresting  by  the  physician,  yet  woe- 
fully in  need  of  proper  direction. 

Various  systems  for  the  management  of  this  type  of 


TREATMENT  OF  FATIGUE  STATES        85 

cases  have  been  advanced  by  different  men.  The  earliest 
complete  method  was  that  recommended  by  Dr.  S.  Weir 
Mitchell,  and  has  since  been  referred  to  as  the  rest  cure. 
In  1875  he  published  his  first  paper  treating  of  this  sub- 
ject under  the  title  of  "  Rest  and  the  Treatment  of  Nerv- 
ous Diseases,"  and  a  few  years  later  brought  forth  the' 
first  edition  of  his  monograph  "  Fat  and  Blood."  As  is 
well  known,  the  essence  of  his  method  consists  in  pur-' 
suing  his  course  along  certain  definite  lines,  treating  all 
cases  alike.  Seclusion,  rest,  massage,  electricity,  and 
feeding  have  been  the  points  on  which  he  has  laid  par- 
ticular stress.  That  he  has  been  eminently  successful  in 
carrying  out  this  method  can  be  attested  by  the  large 
number  of  patients  who  have  been  benefited  under  his 
care.  That  the  principles  he  employs  exercise  their  re- 
sults according  to  his  theories  is,  however,  a  question. 
It  has  been  poinded  out  by  Prince  and  others  that  the 
point  on  which  he  lays  special  stress,  namely  the  increas- 
ing of  the  body  weight  and  the  production  of  more  blood, 
does  not  by  any  means  lead  to  the  amelioration  of  func- 
tional nervous  symptoms ;  that  although  change  of  sur- 
roundings may  prove  beneficial  in  many  cases,  complete 
isolation  undoubtedly  does  harm  in  certain  types,  and 
that  the  general  result  produced  by  the  completeness  of 
the  regime  owes  its  success  rather  to  the  suggestive  in- 
fluence than  to  any  physical  change  that  takes  place. 
This  system  has  been  more  or  less  widely  adopted  with 
modifications  by  most  of  the  sanitaria  devoted  to  the 
treatment  of  nervous  invalids,  and  the  criticisms  which 
may  be  applied  to  this  method  as  employed  by  its  orig- 
inator are  even  truer  here.  For,  lacking  the  unusual 
personality  of  the  father  of  this  regime,  and  the  confi- 
dence inspired  by  his  continued  successes,  the  patient  is 
too  ready  to  accept  the  "  rest  cure  "  as  such,  in  every 
sense  of  the  word,  and  thus  derive  from  it  the  feature 


86  PSYCHOTHERAPEUTICS 

which  should  be  minimized,  while  he  misses  in  so -doing  the 
factor  which  should  be  working  against  his  psychic  atti- 
tude toward  his  condition. 

This  has  been  so  much  recognized  by  many  of  the  sani- 
taria during  recent  years  that  the  facilities  for  exercise 

%and  occupation  have  to  a  large  extent  replaced  those  of 
rest  and  seclusion  with  gratifying  results. 

A  new  impetus  has  been  given  to  the  interest  in  psycho- 
therapeutics by  the  widespread  reading  of  the  methods 
of  Dubois,  as  set  forth  in  his  book,  "  The  Psychic  Treat- 
ment of  Nervous  Disorders,"  published  in  1905.  This 
method,  which  has  been  termed  the  system  of  rational 

/  therapeutics,  has  for  its  aim  the  education  of  the  patient 
oftentimes  through  more  or  less  Spartan  discipline,  and 
through  the  presentation  of  bare  facts  and  truths  re- 
gardless of  the  patient's  attitude  towards  his  own  condi- 
tion. Whereas  the  method  followed  by  Mitchell  with  its 
modifications  as  advocated  by  Dejerine  and  Barker  have 
been  to  rest  and  isolate  the  patient  and  gradually  win 
him  from  his  symptoms  by  education  as  to  their  nature, 
and  encouragement,  meanwhile  treating  the  various  dis- 
comforts and  increasing  the  patient's  powers  for  activ- 
ity, Dubois,  on  the  other  hand,  begins  by  explaining  to 

/  the  patient  the  actual  condition  of  things,  and  forces  his 
opinion  as  to  the  psychic  nature  of  the  discomfort,  and 
refuses  treatment  of  this  by  drugs  or  chemical  means. 
"  Never,"  said  Dubois,  in  discussing  the  use  of  drugs  a 
short  time  ago,  "  will  I  give  a  sleeping  powder  to  a  nerv- 
ous patient  except  in  cases  of  actual  melancholia." 
Whether  this  method  can  be  generally  adopted  by  prac- 
titioners is  a  great  question.  The  remarkable  personal- 
ity of  Dubois,  and  his  firm  conviction  as  to  the  ethical 
and  therapeutic  value  of  his  method,  render  it  peculiarly 
efficient.  It  is  difficult  to  conceive  of  a  patient  not  being 
strongly  moved  by  his  remarks,  which  are  presented  by 


TREATMENT  OF  FATIGUE  STATES         87 

him  so  forcibly,  and  clinched  by  his  frequent  repetition 

of  his  favorite  phrase,  "  C'est  la  verite."  . 

It  is   apparent   that   the  mental   attitude   of  patients  v-^ 
suffering  from  this  chronic  state  must  be  changed.     New         / 
groups  of  complexes   must  be   formed.     The  knowledge 
that  experience  has  shown  that  certain  sensations  have 
resulted  from  certain   activities  must  be  replaced  by  a 
conviction  that  these  efforts  may  be  made  without  harm. 

Whether  the  result  may  better  be  brought  about  by 
the  establishment  of  new  complexes  in  the  hypnotic  state,  O 
or  by  persuasion  and  conviction  established  in  the  waking 
state,  may  be  a  question  in  some  cases.  If  we  are  to 
consider  that  the  unhealthy  complexes  dominant  in  these 
cases,  rendering  them  unable  to  respond  in  a  normal  way 
to  their  surroundings,  are  to  be  looked  upon  as  a  disso- 
ciation, much  as  moods  of  depression  are  to  be  regarded, 
hypnosis  may  be  offered  as  a  rational  method  for  estab- 
lishing the  normal  state.  Both  Tuckey  and  Bramwell 
have  reported  cases  in  which  the  fatigue  state  has  been 
successfully  treated  in  this  way. 

Personally  I  have  used  the  conversation  method  prac- 
ticed by  Dubois.  Needless  to  say,  the  physical  condi- 
tion must  be  thoroughly  investigated  and  any  deficiencies 
recognized,  while  it  should  be  assured  that  the  bodily 
secretions  are  functioning  in  a  normal  manner. 

At  the  start,  the  attitude  of  the  patient  toward  his  ^ 
condition  must  be  changed.     The  discouraged  doldrum  \ 
state  must  be  attacked  by  a  careful  and  truthful  state- 
ment of  the  existing  condition,  and  the  possibilities  set 
forth  which  must  be  attained,  and  will  result  as  surely 
as  the  physical  law  of  cause  and  effect  is  true.     He  must 
regard  his  condition  in  a  new  light,  and  new  groups  of 
complexes  must  be  called  into  play  and  associated  with 
his  individual  symptoms  as  well  as  with  his  attitude  to-  v 
ward  the  future. 


88  PSYCHOTHERAPEUTICS  j 

When  physical  or  mental  effort  is  called  into  play  the} 
fatigue  or  discomfort  resulting  should  call  up  the  new' 
complexes  established,  and  in  order  that  this  may  follow, 
the  association  of  the  new  complex  groups  must  be  more 
strongly  welded  to  the  symptoms  than  are  the  old  groups 
of  discouragement,  indifference,  fears,  etc.  It  is  here 
that  the  mistake  is  too  frequently  made  of  using  general 
unmethodical  encouragement,  in  place  of  strengthening 
the  association  between  the  desired  complexes  and  the 
tasks  to  be  performed.  This  is  not  to  be  accomplished 
in  a  hasty  consultation,  but  the  physician  must  spend 
sufficient  time  to  feel  himself  thoroughly  "  en  rapport  " 
with  his  patient,  so  that  both  have  a  tacit  understanding 
that  they  are  taking  up  a  task  together  which  is  going 
to  be  accomplished.  Enthusiasm  for  the  undertaking, 
increasing  amounts  of  activity,  and  occupation  best 
suited  to  the  individual,  form  steps  by  which  the  patient 
may  mount  to  his  normal  plane. 

The  rational  acceptance  of  the  feeling  of  fatigue  must 
be  forced  upon  him  until  it  becomes  for  him  a  natural 
reflex,  and  this  carries  him  a  long  way  towards  disregard- 
ing it,  and  its  final  disappearance.  Frequently  the  pa- 
tient remarks,  "  Yes,  doctor,  I  have  done  as  you  said, 
but  I  feel  so  tired."  "  That  may  be  true,"  is  the  reply, 
"  but  you  were  just  as  tired  last  week,  and  then  you  were 
accomplishing  nothing.  The  difference  is,  that  to-day 
you  are  so  much  nearer  the  goal." 

I  am  not  in  accord  with  the  belief  of  Dubois  that  abso- 
lute disregard  of  all  symptoms  depending  on  the  psychic 
state  should  be  enforced  upon  the  patient.  Certainly  the 
road  is  a  much  easier  one  for  him  to  travel  if  the  dis- 
tressing head  feelings  are  alleviated  by  a  static  current, 
or  if  a  gastric  disorder  is  controlled  by  some  simple 
remedy.  The  danger  is  to  be  avoided,  however,  of  too 
much  treatment  of  this  sort. 


TREATMENT  OF  FATIGUE  STATES        89 

The  following  cases  are  illustrative  of  the  conditions 
which  may  be  benefited  by  these  methods. 

Case  I.  This  patient  was  a  student  twenty-one  years 
of  age.  His  father  and  mother  were  both  of  neurotic 
families,  and  were  themselves  subject  to  moods  of  depres- 
sion, while  his  sister  was  of  a  high  strung  and  sensitive 
temperament.  The  patient  had  always  been  strong  and 
rugged  physically,  and,  except  for  certain  disturbing 
ideas  in  real  life  such  as  come  to  imaginative  children, 
had  never  had  any  nervous  disorders.  Slow  to  learn,  he 
had  found  it  difficult  to  pass  the  entrance  examinations 
to  college,  and  had  some  difficulty  in  keeping  up  with  his 
class  work.  This  was  the  more  difficult  o'^  account  of 
his  love  of  sports.  His  whole  ambition  seemed  to  be  to 
make  the  'Varsity  team  in  football.  His  continued  ef- 
forts to  do  well  in  his  studies,  with  his  constant  worry 
lest  he  should  not  be  able  to  do  well  in  his  athletics,  caused 
him  toward  the  middle  of  his  first  year  in  college  to  be- 
come more  and  more  fatigued.  This  sense  of  weariness 
once  started  developed  more  rapidly,  and  made  it  nearly 
impossible  for  him  to  accomplish  any  work.  In  fact,  so 
pronounced  was  the  symptom,  that  repeatedly,  on  simply 
crossing  the  college  yard,  he  returned  to  his  room  so 
exhausted  that  he  felt  obliged  to  lie  down  and  rest. 

His  inability  to  keep  up  with  his  duties  caused  him 
greater  and  greater  worry,  and  he  suffered  constantly 
from  his  head  feeling  tired,  which  rendered  it  impossible 
for  him  to  concentrate  his  mind  any  length  of  time.  This 
tired  feeling  in  the  head  soon  gave  way  to  a  constant 
sense  of  pressure  over  the  forehead  and  the  vertex,  which 
caused  him  much  alarm.  Frequently  when  this  was  very 
distressing,  he  would  be  seized  with  the  idea  that  he 
was  going  to  lose  his  mind. 

A  careful  examination  of  the  patient  showed  an  almost 
perfect    physical    condition.     Never    have    I    seen    more 


90  PSYCHOTHERAPEUTICS 

splendid  muscular  development.  There  was  no  evidence 
of  any  disturbance  of  the  organs  of  the  thoracic  or  the 
abdominal  cavities.  The  pupils  were  normal  in  size  and 
reacted  well.  The  knee  jerks  were  equal  and  slight.  The 
contrast  between  his  story  of  utter  physical  exhaustion, 
and  the  picture  he  presented  of  such  strength  was  very 
striking.  Nor  was  he  able  to  understand  why  he  could 
not  enter  Into  things  with  his  customary  vigor.  After 
explaining  in  detail  to  him  the  nature  of  his  condition 
and  the  factors  which  were  helping  to  keep  him  frcma 
recovery,  he  was  made  to  realize  what  his  possibilities 
were,  and  how  he  must  apply  himself  to  gain  his  ends. 
The  tasks  put  upon  him  were  made  rapidly  more  and  more 
difficult,  so  that  at  the  end  of  six  weeks  he  was  doing  a 
normal  amount  of  studying,  and  was  rated  as  one  of  the 
first-class  men  in  putting  the  shot  and  throwing  the  ham- 
mer. 

His  condition  continued  to  improve  so  that  the  fol- 
lowing fall  he  played  on  the  'Varsity  football  team,  and 
then  as  well  as  during  the  two  succeeding  years  of  play 
was  considered  a  tower  of  strength. 

Except  for  a  temporary  difficulty  of  an  entirely  differ- 
ent nature  this  patient  has  been  quite  well  since  his  re- 
covery, a  period  now  of  several  years. 

Case  II.  The  second  patient  was  a  strong,  well-look- 
ing man  of  twenty-two,  who  for  years  had  been  inca- 
pacitated for  carrying  on  the  work  of  daily  life  on  ac- 
count of  his  nervous  condition. 

A  few  years  ago  he  was  working  very  hard  in  college, 
and  studying  In  a  law  office  in  addition.  This  he  was  able 
to  keep  up  for  a  year,  although  he  grew  progressively 
more  tired,  and  found  himself  more  and  more  limited  In 
his  capacity  for  performing  his  duties.  At  the  end  of 
this  time,  one  evening  when  he  arrived  at  his  home,  as 
he  was  going  upstairs  he  was  suddenly  overpowered  with 


TREATMENT  OF  FATIGUE  STATES        91 

a  sensation  as  if  he  were  let  down  through  a  stairway, 
and  were  melting  away  into  nothingness,  and  was  con- 
scious of  a  feeling  of  overpowering  fear.  A  cold  sweat 
broke  out  all  over  him,  so  that  he  got  hot  water  bottles 
and  crawled  into  bed  under  heavy  coverings,  still  feeling 
strange.  From  that  night  on,  the  feeling  of  exhaustion 
which  had  been  increasing  for  a  number  of  months  be- 
came doubly  strong,  and  rendered  him  unable  to  carry 
on  his  work  and  studies.  In  the  mean  time  similar  at- 
tacks of  fear  and  unreality  returned  at  various  intervals, 
and  he  was  advised  to  leave  his  home  and  to  enter  a 
sanatorium. 

The  following  two  years  were  spent  in  various  sana- 
toria and  retreats,  the  patient  meanwhile  getting  no 
stronger,  but  more  and  more  losing  confidence  in  him- 
self. At  the  time  when  he  made  his  first  visit  to  me  he 
was  unable  to  go  about  alone  on  account  of  his  great 
sense  of  fear  that  something  would  happen.  The  out- 
side world  seemed  strange  in  a  way  which  he  found  it 
difficult  to  explain.  There  was  no  power  to  concentrate 
the  attention  in  following  a  conversation  or  in  attempt- 
ing to  read;  to  such  a  degree  did  this  symptom  exist 
that  he  found  it  impossible  to  read  a  single  paragraph 
in  the  newspaper  understandingly.  Attempts  to  move 
about  simply  rendered  him  more  tired,  and  on  the  whole 
he  declared  himself  utterly  discouraged  in  trying  to  make 
any  progress  against  his  illness. 

The  treatment  of  the  condition  was  rendered  difficult 
in  the  beginning  by  the  inability  of  the  patient  to  give 
his  attention  long  enough  to  grasp  a  continued  line  of 
argument.  This  was  overcome  gradually  by  forcing 
him  to  devote  all  his  energies  to  mastering  the  content 
of  longer  and  longer  passages  of  reading  at  stated  in- 
tervals, till  he  found  himself  able  to  read  or  attend  lec- 
tures   without    effort.     Meanwhile    his    fears    were    dis- 


9^  PSYCHOTHERAPEUTICS 

pelled  by  the  substitution  of  new  complexes,  so- that  now 
for  a  year  he  has  been  carrying  on  more  work  than  is 
done  by  the  average  law  student,  and  performing  his  du- 
ties in  an  eminently  satisfactory  manner. 

Whereas  the  first  case  cited  represents  the  psychical 
fatigue  (hyperesthesia)  as  related  more  to  physical  ef- 
fort, the  second  case  is  the  type  in  which  a  physiological 
fatigue  state  developed  into  a  psychopathological  fa- 
tigue and  finally  into  a  condition  of  psychasthenia. 
Such  cases  at  times  have  the  distressing  attacks  of  un- 
reality and  the  overpowering  fears  developed  to  such  a 
degree  that  hypnosis  is  necessary  to  overcome  them. 
That  new  complexes  may  be  forced  upon  them  in  the 
waking  state  when  the  distressing  symptoms  are  not  too 
deeply  grounded  is  evidenced  by  the  frequency  with 
which  this  end  has  been  accomplished. 


I 


I 


CHAPTER  FIVE 

Psycho-analysis  in  Psychotherapy 

BY    EENEST    JONES,    M.D.,    M.R.C.P.     (lOND.J 

London 

THE  evolution  of  psychotherapy,  like  that  of  all 
other  modes  of  treatment,  is  marked  by  an  ever- 
increasing  precision  in  method  and  an  ever-deepen- 
ing comprehension  of  the  conditions  to  which  it  is  ap- 
plicable. Progress  in  these  two  respects  must  always 
go  hand  in  hand,  for  the  moment  therapeutics  becomes 
divorced  from  pathology  and  diagnosis  it  leaves  its  scien- 
tific basis  and  stands  in  danger  of  approximating  to  that 
medical  charlatanery  which  it  is  the  highest  interest  of 
our  profession  to  resist.  The  two  studies  are  peculiarly 
interwoven  in  the  case  of  the  psycho-analytic  form  of 
psychotherapy,  for,  as  I  shall  presently  indicate,  treat- 
ment is  here  carried  out  by' simultaneously  laying  bare 
and  remedying  the  pathological  mechanisms  at  the  basis 
of  the  malady.  From  this  point  of  view  we  can  discern 
two  stages  in  the  development  of  any  new  method  of 
treatment,  and  these  I  can  best  illustrate  by  a  reference 
to  more  familiar  methods,  for  instance  the  operations  of 
trephining  or  of  laparotomy.  When  the  possibility  of 
these  operations  was  first  realized  we  saw  the  first  stage 
in  development,  in  which,  namely,  they  were  regarded 
merely  as  an  adjunct  to  the  therapeutic  armamentarium, 
and  were  applied  in  the  relief  of  conditions  that  were  al- 
ready well  known  and  studied  on  established  patholog- 
ical lines.  The  second  stage  arose  when,  through  the 
repeated  performance  of  such  operations,  conditions  that 

93 


94  PSYCHOTHERAPEUTICS 

could  be  relieved  by  them  came  to  be  studied  anew,  fresh 
aspects  of  pathology  opened  up,  and  questions  of  pre- 
cise diagnosis  that  had  previously  been  academic  prob- 
lems of  trivial  interest  now  became  urgent  matters  of 
life  and  death.  A  moment's  reflection  on  the  history  ot 
appendicitis  will  remind  you  of  how  little  we  knew  of 
the  pathology,  the  diagnosis,  or  even  the  existence  of  the 
affection  until  the  surgeon's  knife  showed  that  it  could 
be  cured.  We  might,  in  fact,  paraphrase  the  motto  un- 
derlying British  Imperialistic  policy,  to  wit,  that  trade 
follows  the  flag,  and  say  that  in  medicine  diagnosis  fol- 
lows  treatment. 

Now  in  psychotherapy  most  of  the  medical  world  is  at 
present  only  entering  on  the  first  stage.  That  the  med- 
ical world  of  America  will  definitely  enter  on  this  stage 
as  a  prelude  to  further  advancement  will,  I  trust,  be  one 
of  the  results  of  this  present  symposium.  In  this 
stage  we  clearly  recognize  that  we  have  secured  a  new 
therapeutic  weapon  of  the  utmost  value,  which  we  may 
describe  as  the  capacity  to  alleviate  certain  complaints 
by  purely  mental  measures,  in  other  words  as  psycho- 
therapy in  its  broadest  sense.  Our  attitude  towards  the 
nature  of  these  complaints,  however,  remains  in  this  stage 
substantially  the  same  as  it  was  when  they  were  treated 
only  by  physical  remedies.  Hence  we  may  see  the 
strange  picture  of  a  physician  removing  by  verbal  sug- 
gestion a  symptom  which  he  considers  is  produced  by  a 
toxin  circulating  in  the  blood.  However,  a  thoughtful 
person  who  employs  any  form  of  psychotherapy  soon 
realizes  that  a  symptom  which  can  be  removed  by  mental 
measures  is  in  all  probability  of  a  mental  nature.  It 
may  parenthetically  be  remarked  that  he  further  real- 
izes how  the  suffering  endured  by  the  patient,  so  far  from 
being  unreal,  is  all  the  more  dreadful  and  formidable  for 
having  a  mental  and  not  a  physical  origin.     A  non-ap- 


PSYCHO-ANALYSIS  IN  PSYCHOTHERAPY      95 

preciation  of  this  important  fact  is  still  all  too  common. 
Only  recently  an  article  appeared  in  one  of  the  leading 
medical  journals  in  which  the  writer  remarked:  "In  this 
manner  I  hope  that  we  will  always  be  able  to  trick  a 
malingerer  or  hysterical  subject  into  betraying  the 
falsity  of  his  claim."  This  attitude,  though  rarely  in 
such  an  outspoken  form,  is  frequently  implied  in  medical 
writings,  and  cannot  be  too  strongly  condemned.  Apart 
from  yielding  an  inkling  of  the  mental  nature  of  various 
disorders,  the  first  stage  in  the  evolution  of  psycho- 
therapy is  characterized  by  an  indeterminate  attitude 
towards  the  origin  and  pathogenesis  of  them.  The 
older  conceptions  have  begun  to  dissolve,  but  the  knowl- 
edge won  by  the  new  method  of  treatment  has  not  yet 
been  formulated.  Psychotherapy  is  in  this  stage  em- 
ployed in  a  quite  empiric  way,  and  the  physician  either 
does  not  concern  himself  with  the  intrinsic  modus  operandi 
of  his  treatment,  or  else  offers  explanations  of  it  which 
are  so  superficial  as  to  be  of  little  scientific  value. 

Psycho-analysis  represents  the  second  stage  in  the 
evolution  of  psychotherapy.  Here  a  deeper  insight  is 
sought  into  the  essential  nature  and  origin  of  the  morbid 
phenomena  with  a  view  to  obtaining  a  fuller  understand- 
ing of  the  aims  of  treatment  and  so  to  achieving  a 
greater  precision  in  the  application  of  it.  The  psycho- 
analytic method  we  owe  almost  completely  to  the  genius 
of  Professor  Freud  of  Vienna,  who'  in  the  past  sixteen 
years  has  wrought  it  into  an  elaborate  science  of  which 
I  can  here  give  only  the  most  summary  outline.  The 
method  is  based  on  the  knowledge  that  the  symptoms 
present  in  the  psycho-neuroses  owe  their  origin  to  a  con- 
flict between  two  groups  of  ideas  or  mental  processes 
which  cannot  be  brought  into  harmony  with  each  other. 
One  complex  of  mental  processes  is  for  some  reason  or 
other  of  such  a  kind  as  to  be  inacceptable  to  the  main 


96  PSYCHOTHERAPEUTICS 

body  of  the  personality.  The  personality  fails,  to  assim- 
ilate it,  will  have  nothing  to  do  with  it,  tries  to  forget  it, 
to  submerge  it,  to  repress  it.  The  repressed  complex 
then  takes  on  an  automatic  existence,  and  acts  as  an  ir- 
ritating foreign  body  in  the  same  way  as  any  physical 
foreign  body  that  has  not  been  absorbed.  From  this 
point  of  view  we  may  define  the  pathology  of  the  psycho- 
neuroses  as  a  defect  in  assimilation. 

Let  me  illustrate  my  meaning  with  a  concrete  instance. 
A  man  conceives  an  attraction  toward  the  wife  of  a  near 
friend  or  relative,  and  in  his  imagination  perhaps  plays 
with  the  thought  of  what  might  happen  were  the  friend 
to  meet  with  a  fatal  accident.  If  he  honestly  faces  his 
wish  and  realizes  its  nature  he  will  instantly  see  that, 
though  possibly  a  perfectly  natural  one,  it  is  of  such  a 
kind  that  for  social  and  ethical  reasons  it  must  obviously 
be  suppressed.  If  he  adopts  this  healthy  attitude  he  will 
probably  think  no  more  about  the  matter  except  in  the 
most  harmless  way.  The  wish-complex  is  here  assimi- 
lated by  the  main  body  of  the  personality.  If  on  the 
other  hand  he  regards  the  mere  possibility  of  entertain- 
ing such  a  wish  as  a  sin  and  a  sign  of  the  most  desperate 
iniquity  he  may  refuse  to  own  up  to  himself  that  he  has 
ever  felt  it,  even  momentarily ;  whenever  the  thought  oc- 
curs to  him  he  endeavors  to  put  it  from  him,  to  get  away 
from  it,  in  other  words  to  repress  (' verdrangen ')  it. 
The  complex  here  is  not  assimilated,  it  therefore  con-' 
tinues  to  act,  and  the  more  the  man  strives  to  escape 
from  it,  the  more  hauntingly  does  it  torment  him.  He 
has  now  become  the  prey  to  a  fixed  idea  which  is  out  of 
his  control,  and  which  evinces  its  independence  by  ap- 
pearing irregularly  whether  he  wills  it  or  not.  In  actiial 
practice  we  never  meet  with  cases  so  simple  as  this,  but 
the  instance  will  serve  to  illustrate  the  notion  I  am  trying 
to   convey,   namely   that   certain   mental  processes,  par- 


PSYCHO-ANALYSIS  IN  PSYCHOTHERAPY      97 

ticularly  strivings,  desires,  and  impulses,  if  they  are  not 
absorbed  in  the  main  stream  of  the  personality  are  apt 
to  manifest  an  independent  activity  out  of  control  of  the 
will.  This  activity  is  usually  of  a  low  order,  of  an  auto- 
matic and  almost  reflex  kind,  and  —  if  I  may  be  allowed 
to  use  the  term  in  a  clinical  and  non-philosophic  sense 
—  it  is  generally  an  unconscious  activity,  that  is  to 
say  it  operates  without  the  subject's  being  aware  of 
it. 

As  I  have  just  said,  matters  are  not  so  simple  in  prac- 
tice, and  what  actually  happens  is  that  the  activity  of 
the  repressed  complex  is  manifested  not  directly  but  in- 
directly in  some  distorted  form  that  is  often  hard  to  rec- 
ognize. In  the  above  example,  for  instance,  the  subject 
might  have  counterbalanced  his  real  attitude  towards 
his  friend  by  developing  an  exaggerated  solicitude  for 
his  welfare,  and  have  shown  great  concern  and  dread 
whenever  the  friend  ran  the  slightest  risk  of  accident  or 
danger.  Again,  an  abnormally  strong  emotion  might  be 
evoked  by  anything  accidentally  associated  with  the  per- 
sons in  question,  a  condition  that  Professor  Morton 
Prince  described  some  ten  years  ago  under  the  name  of 
"  association  neurosis."  This  distortion  in  the  mani- 
festation of  the  activity  of  the  mental  complex  is  often 
exceedingly  involved,  and  one  of  the  main  difficulties  in 
the  psycho-analytic  method  is  the  unravelling  of  the  con- 
fused end-product,  which  clinically  we  call  a  symptom. 
The  psychological  mechanisms  by  means  of  which  the 
distortion  is  brought  about  are  very  intricate,  so  that  in 
the  time  allotted  it  would  be  impossible  for  me  to  de- 
scribe them.  They  have  been  worked  out  with  great 
accuracy  and  detail  by  Freud  and  Jung,  and  an  exact 
study  of  them  is  essential  to  the  use  of  the  psycho- 
analytic method. 

Investigation   on   the  lines   presently  to  be  indicated 


98  PSYCHOTHERAPEUTICS 

discloses  the  fact  that  every  psycho-neurotic  symptom  is 
to  be  regarded  as  the  symbolic  expression  of  a  submerged 
mental  complex  of  the  nature  of  a  wish.  The  wish  itself 
on  account  of  its  inacceptable  nature  is  concealed,  and 
the  symptom  arises  as  a  compromise  between  it  and  the 
repressing  force  exerted  by  the  main  personality.  The 
stream  of  feeling  that  characterizes  the  wish  is  dammed 
up,  it  can  find  no  direct  outlet,  and  so  flows  into  some 
abnormal  direction.  The  metaphor  of  "  side-tracking  " 
is,  I  believe,  used  in  American  psychiatric  circles  to  in- 
dicate this  process.  In  more  technical  phraseology  we 
may  say  that  the  affect  of  the  original  complex  is  in- 
hibited, and  so  becomes  transposed  on  to  an  indifferent 
mental  process.  This  indifferent  mental  process  has  now 
become  invested  with  the  strength  of  feeling  that  prop- 
erly belongs  to  the  original  complex,  and  so  may  be  said 
to  replace  the  complex.  Thus  arises  what  Professor 
Adolf  Meyer  calls  a  substitution  neurosis,  in  which  an 
abnormal  outlet  has  been  found  for  a  pent-up  affective 
process.  The  outlet  may  be  in  a  purely  mental  direc- 
tion, in  which  case  we  have  such  a  symptom  as  a  phobia, 
or  towards  various  bodily  processes,  a  condition  that 
Freud  calls  conversion-hysteria,  in  which  case  we  have 
such  symptoms  as  a  tremor  or  a  paralysis.  In  the 
symptom  the  patient  obtains  a  certain  unconscious  grat- 
ification of  the  repressed  wish,  and  this  means  of  obtain- 
ing the  gratification,  however  perverse  and  abnormal  it 
may  be,  is  still  the  only  means  possible  to  the  patient 
under  the  circumstances.  This  fact  explains  the  ob- 
stinacy with  which  such  a  patient  may  instinctively  cling 
to  his  symptoms,  and  is  one  of  the  causes  of  the  resistance 
that  the  physician  encounters  when  trying  to  remove 
these.  I  need  hardly  remind  you  that  this  obstinacy  is 
often  erroneously  interpreted  even  by  physicians  as  in- 
dicating mere  wilful  perversity,  a  mistake  that  does  not, 


J 


PSYCHO-ANALYSIS  IN  PSYCHOTHERAPY      99 

conduce  to  success  in  treatment.  Not  only  does  the  ob- 
server commonly  fail  to  understand  the  significance  of 
the  sjmptom,  but  the  patient  himself  has  no  knowledge 
of  its  meaning  or  origin.  In  fact,  enabling  the  patient 
to  discover  and  appreciate  the  significance  of  the  mental 
process  that  manifests  itself  as  a  symptom  is  the  central 
aim  of  the  psycho-analytic  method, 
'  In  carrying  out  this  method  several  procedures  may  be 
adopted  according  to  circumstances.  The  hypnotic 
state,  for  instance,  may  be  utilized  in  the  search  for  for- 
gotten memories.  Only  a  very  few  of  those  acquainted 
with  the  psycho-analytic  method  employ  this  procedure 
at  all  extensively,  for  it  has  grave  disadvantages  which 
I  need  not  here  discuss.  Personally  I  employ  it  only  as 
a  rare  exception  and  for  special  reasons ;  under  certain 
circumstances,  however,  it  undoubtedly  has  a  legitimate 
place.  The  procedure  introduced  and  developed  by 
Freud  is  the  one  most  generally  used,  and  gives  by  far 
the  most  satisfactory  results.  It  is  one  of  the  ways  of 
obtaining  what  is  known  in  psychology  as  "  free  associa- 
tion," and  is  carried  out  by  getting  the  patient  ta  con- 
centrate his  mind  on  a  given  idea,  generally  one  in  rela- 
tion to  a  symptom,  and  asking  him  to  relate  in  the  order 
of  their  appearance  the  various  thoughts  that  come  to 
his  mind.  It  is  essential  for  him  to  do  this  quite  hon- 
estly, and  fortunately  we  have  several  objective  tests  of 
his  behavior  in  this  respect.  He  must  suspend  his  nat- 
ural tendency  to  criticize  and  direct  the  thoughts  flow- 
ing in,  and  must  therefore  play  a  purely  passive  part 
during  this  stage.  At  first  he  will  omit  to  mention  a 
number  of  thoughts  on  the  ground  that  they  are  appar- 
ently irrelevant,  unimportant,  or  nonsensical,  and  others 
because  they  are  of  a  painful  or  unpleasant  nature. 
After  a  time,  however,  the  length  of  which  largely  de- 
pends on  his  intelligence  and  sincerity,  he  acquires  the 


100  PSYCHOTHERAPEUTICS  ^ 

capacity  of  adopting  the  non-critical  and  passive  atti- 
tude essential  to  success. 

Other  means  of  reaching  buried  mental  complexes  may 
briefly  be  mentioned.  A  study  of  various  mannerisms, 
symptomatic  movements  and  tricks  of  behavior,  and  slips 
of  the  tongue  or  pen,  often  reveals  the  automatic  func- 
tioning of  some  repressed  train  of  thought.  The  word- 
reaction  association  method  as  developed  by  Jung  is  of 
the  highest  assistance,  particularly  in  furnishing  us  with 
a  series  of  clues  to  serve  as  starting  points  for  future 
analyses.  In  this  method  a  series  of  test-words  are 
called  out  to  the  patient,  who  has  to  respond  with  the 
first  word  or  thought  thus  called  to  his  mind.  From  a 
general  review  of  the  kind  of  responses  given  much  can 
be  learned  about  the  mentality  of  the  patient  and  the 
type  of  psychosis  present.  Further,  by  noting  certain 
peculiarities  in  the  individual  reactions  we  may  discover 
certain  complexes  or  trains  of  thought  which  possess  for 
the  patient  a  high  emotional  value,  and  these  can  then 
be  followed  and  studied  more  fully.  The  peculiarities  I 
refer  to  are  ten  or  twelve  in  number.  The  chief  are: 
undue  delay  in  the  time  of  reaction,  failure  to  respond 
at  all,  response  by  repetition  of  the  test-word,  persevera- 
tion affecting  the  succeeding  reactions,  anomalous  clang 
associations,  assimilation  of  the  test-word  in  an  unusual 
sense,  and  erroneous  reproduction  of  the  reaction  when 
the  memory  for  it  is  subsequently  tested.  Last  but  not 
least  is  the  analysis  of  the  patient's  dreams  by  means  of 
the  special  technique  introduced  by  Freud.  The  study 
of  dreams  is  in  this  connection  of  supreme  importance, 
for  of  all  the  means  at  our  disposal  it  is  the  one  that  best 
enables  us  to  penetrate  into  and  understand  the  most 
hidden  parts  of  the  mind.  No  one  can  have  more  than 
an  outsider's  notion  of  the  psycho-analytic  method  who 
has  not  thoroughly  studied  Freud's  Traumdeutungy  for 


I 


PSYCHO-ANALYSIS  IN  PSycHOTHERAPY    101 

in  this  work  he  has  laid  down  the  ^etifiiiiqiie '  oi' his  iatthr 
ods,  and  discussed  the  principles  on  which  they  are  based, 
with  a  fulness  to  be  found  nowhere  else  in  his  writings. 

By  means  of  the  methods  just  outlined  we  are  enabled 
to  determine  the  origin  of  the  symptom  by  retracing  the 
steps  along  which  its  pathogenesis  proceeded.  It  is  im- 
possible to  deal  with  the  underlying  complexes,  to  dis- 
charge their  pent-up  affect,  to  render  them  more  assim- 
ilable by  the  patient,  unless  one  succeeds  in  this  task  and 
brings  them  to  the  full  light  of  day.  The  symptoms 
constitute  a  veiled  language  in  which  hidden  thoughts 
and  desires  find  the  only  means  allowed  them  of  coming  to 
expression.  We  have  to  get  the  patient  to  translate  his 
symptoms  into  more  direct  language,  and  thus  to  under- 
stand and  appreciate  the  origin  of  them.  In  so  doing 
we  give  the  patient  a  deeper  insight  into  the  workings 
of  his  mind,  so  that  he  is  enabled  to  correct  abnormal 
deviations,  to  overcome  internal  inhibitions  and  impedi- 
ments, and  to  acquire  a  more  objective  standpoint  to- 
wards the  repressed  mental  complexes,  the  automatic 
functioning  of  which  has  produced  the  morbid  manifesta- 
tions. He  is  in  this  way  able  to  free  his  personality 
from  the  constraining  force  of  these  complexes,  and,  by 
taking  up  an  independent  attitude  towards  them,  to  gain 
a  degree  of  self-control  over  his  aberrant  thoughts  and 
wishes  that  was  previously  impossible.  The  method  is 
thus  in  almost  every  respect  the  reverse  of  treatment  by 
suggestion,  although  several  would-be  critics  have 
naively  exposed  their  ignorance  of  the  subject  in  main- 
taining that  the  successful  results  are  produced  by  sug- 
gestion. In  suggestion  treatment  the  physician  adds 
something  to  the  patient's  mind, —  confidence,  belief,  etc., 
—  and  thus  makes  the  patient  more  dependent  on  him. 
The  psycho-analytic  method  does  not  add;  it  takes  away 
something,  namely  inhibition.     It  enables  the  patient  to 


102  PSYCHQTHERAPEUTICS 

disentangi^  confu'sed  mental  processes,  and,  bj  giving 
him  control  over  the  disharmonies  of  his  mind,  leads  him 
to  develop  a  greater  measure  of  self-reliance  and  inde- 
pendence. The  training  received  by  the  patient  is  thus 
an  educative  one  in  the  highest  sense  of  the  word,  for  he 
not  only  achieves  a  richer  development  of  will  power  and 
self-mastery,  but  acquires  an  understanding  of  his  own 
mind  which  is  of  incalculable  value  for  future  prophy- 
laxis. He  grows  both  in  capacity  to  know  and  in  ability 
to  do. 

The  conditions  that  lend  themselves  to  psycho-analytic 
treatment  comprise  practically  all  forms  of  psycho-neu- 
rosis, the  different  types  of  hysteria,  the  phobias,  obses- 
sions, anxiety  neuroses,  and  even  certain  kinds  of  sexual 
perversions.  I  shall  refrain  from  relating  any  individ- 
ual cases,  for  to  do  so  would  be  only  to  weary  you  with 
the  recital  of  a  list  of  typical  and  atypical  instances  of 
these  various  conditions.  It  is  further  impossible  for 
me  to  narrate  any  single  instance  of  an  analysis,  for  in 
every  case  the  richness  of  material  is  so  great  that  it 
would  take  several  hours  to  give  even  an  outline  of  the 
main  points  in  the  case. 

The  results  obtained  by  the  treatment,  though  by  no 
means  ideal,  are  yet  very  gratifying.  They  surpass 
those  obtained  by  simpler  methods  in  two  chief  respects, 
namely  in  permanence  and  in  the  prophylactic  value  they 
have  for  the  future.  Although  most  symptoms  can  be 
removed  by  other  methods,  such  as  hypnotism,  yet  any 
one  who  has  devoted  much  time  to  the  study  of  these  cases 
knows  how  great  is  the  tendency  to  relapse,  to  recurrence, 
and  to  the  appearance  of  fresh  groups  of  symptoms. 
Mild^cases  can  indeed  be  not  only  alleviated  but  even 
cured  by  the  simpler  psychotherapeutic  measures,  so  that 
these  all  have  tl]ieiT~sphere  of  usefulness;  severe  cases, 
on  the  other  hand,  need  a  more  radical  treatment,  an 


PSYCHO-ANALYSIS  IN  PSYCHOTHERAPY    103 

uprooting  of  the  actual  morbid  agents.  It  is  easy  to 
understand  how  this  must  be  so.  Hypnotic  jind, other 
suggestion  acts  merely  by  blocking  the  outward  mani- 
f estafioiT  of  theiinderlymg  pathogenetic  idea.  The 
idea  itseir  persists,  because  it  has  not  been  reached  and 
dealt  with,  and  sooner  or  later  it  will  again  manifest  it- 
self either  in  the  same  direction  or  in  some  fresh  one. 
The  analogy  of  a  tubercular,  or  better  still  of  an 
actinomycotic  abscess  occurs  to  me  in  this  connection. 
If  the  suppurating  sinus  is  forcibly  plugged  then  the 
symptom  of  discharging  pus  is  removed,  but  sooner  or 
later  the  pent-up  pus  will  find  a  vent  in  either  the  same 
or  a  fresh  direction.  Before  satisfactory  healing  can 
take  place  the  tension  must  be  relieved  by  instituting 
free  drainage  for  each  pus  pocket,  and  the  more  thor- 
oughly the  focus  of  the  disease  is  dealt  with  the  better 
will  be  the  result. 

A  few  words  are  now  necessary  on  the  clinical  ap- 
plicabilities and  limitations  of  the  method.  It  is  a 
method  that  makes  great  demands  on  both  physician  and 
patient.  Apart  from  technical  knowledge  the  physician 
must  evidently  possess,  not  only  unimpeachable  integrity, 
but  also  a  considerable  measure  of  tact,  patience,  and 
sympathetic  understanding;  without  these  qualifications 
he  is  unlikely  to  gain  the  patient's  confidence  to  the 
requisite  degree.  The  treatment  further  makes  a  great 
call  on  his  time.  Freud  often  finds  it  necessary  to  de- 
vote to  a  patient  an  hour  a  day  for  three  years,  but  he 
acknowledges  that  the  cases  sent  to  him  are  generally  of 
a  very  severe  nature.  In  milder  cases  one  can  achieve 
very  satisfactory  results  in  a  few  months,  a  fact  to  which 
I  can  fully  attest  from  my  own  experience.  The  amount 
of  time  may  appear  excessive  unless  one  remembers  the 
hugeness  of  the  task  imposed,  for  in  all  cases  the  roots 
of  the  trouble  go  back  to  early  childhood,  and  important 


104  PSYCHOTHERAPEUTICS 

modes  of  reactions  have  to  be  altered  which  have  been 
fixed  and  stereotyped  for  many  years.  When  we  con- 
sider how  much  trouble  and  time  frequently  has  to  be 
expended  in  the  orthopedic  straightening  of  a  deformed 
limb,  we  should  not  grudge  the  same  to  the  far  more 
intricate  task  of  the  orthopsychic  training  of  a  deformed 
mind,  especially  when  this  results  in  converting  an  in- 
tolerable existence  into  a  happy  life,  and  a  person  para- 
lyzed by  doubts,  fears,  and  suffering  into  an  active  and 
useful  citizen. 

The  demands  made  on  the  patient  are  no  less  great. 
The  results  of  the  treatment  will  vary  with  the  intelli- 
gence, courage,  honesty,  and  perseverance  he  shows. 
With  stupid  aiid,quite  uneducated  patients  relatively  lit- 
tle can  be  done,  so  that  TiappITy  we  can  most  help  those 
whose  value  to  the  world  is  greatest.  Again,  age  sets  a 
f orrnidable  barrier_to  our  efforts.  In  old  age/when  the 
plasticity  of  the  mind  is  dTmlnrshed,  far  less  can  be  done 
than  at  an  earlier  period,  and  furthermore  the  time  nec- 
essary to  trace  back  the  erroneous  mental  reactions 
through  so  many  years  is  naturally  longer.  Still  I  have 
had  a  few  fairly  satisfactory  results  even  above  the  age 
of  fifty. 

It  will  be  realized  that  the  method  is  at  present  not 
one  generally  applicable  by  the  practising  physician. 
Not  only  is  the  time  necessary  for  the  treatment  a  great 
hindrance,  but  also  a  laborious  special  training  is  neces- 
sary before  the  technique  of  psycho-analysis  can  be  ac- 
quired to  an  adequate  extent.  It  is  generally  admitted 
that  this  demands  three  years'  incessant  practice,  a  good 
previous  knowledge  of  neurology  being  assumed.  Here, 
as  elsewhere,  therefore,  good  work  exacts  arduous  labor, 
and  there  is  no  royal  road  to  the  art  of  handling  the  most 
intricate  and  delicate  machine  we  know  of,  the  human 
mind. 


PSYCHO-ANALYSIS  IN  PSYCHOTHERAPY    105 

You  may  now  legitimately  ask  why  I  have  taken  up  so 
much  of  your  time  in  describing  a  mode  of  treatment 
which  I  acknowledge  not  many  will  have  the  opportunity 
to  learn  or  to  apply.  My  answer  is  a  twofold  one.  In 
the  first  place  I  am  not  one  of  those  who  hold  that  the 
general  physician  should  be  cut  off  from  all  advancing 
knowledge  except  that  which  he  can  immediately  apply 
in  his  daily  work.  No  physician  can  apply  all  methods 
of  diagnosis  and  treatment  but  it  is  surely  well  that  he 
should  at  least  be  aware  of  the  existence  of  them.  I  can- 
not believe  that  because  a  country  practitioner  is  not 
expected  to  apply  the  Wassermann  test  in  the  diagnosis 
of  syphilis,  or  to  perform  excision  of  the  Gasserian 
ganglion  for  the  relief  of  trigeminal  neuralgia,  It  is  there- 
fore better  for  him  not  to  know  about  such  methods. 
In  the  second  place  I  wish  to  contribute  to  the  general 
effect  that  this  symposium  must  have  in  bringing  home 
to  you  in  some  degree  the  present  unsatisfactory  state 
of  medical  education  so  far  as  psychology  is  concerned, 
for  this  is  thejimliLcause^^f  tl^  of  the  med- 

ical profession  against  the  very  maladies  that  are  the 
triumph  of  the  quack,  religious  or  otherwise.  The 
sooner  we  honestly  face  the  shameful  but  undeniable  fact 
that  unqualified  empirics  can  relieve  distressing  affections 
in  cases  that  have  defied  medical  skill,  can  produce  re- 
sults where  we  fail,  the  sooner  will  this  flagrant  lack  in 
our  system  of  education  be  remedied,  and  the  better  will 
it  be  for  the  dignity  and  honour  of  the  medical  profes- 
sion. While  the  present  state  of  affairs  lasts,  in  which 
most  physicians  are  given  not  five  minutes'  training  in 
psychology  in  the  five  years  of  their  student  life,  and  in 
which  there  is  no  teacher  of  clinical  psychology  in  any 
university  or  medical  school  in  the  country,  our  profes- 
sion must  submit  to  being  the  prey  of  the  charlatan  and 
the  mock  of  the  scoffer. 


CHAPTER  SIX 

The    Psycho'?herapeutic    Value    of    the    Hypnoidal 

State 

by  boris  sidis,  m.a.,  ph.d.,  m.d. 

HYPNOSIS  has  long  ago  been  brought  before  the 
scientific  world  as  a  state  in  which  maladies  of 
a  functional  or  of  a  psychic  origin,  such  as  th( 
various  forms  of  hysterias,  obsessions,  and  phobias,  can 
be  helped  and  even  cured.  The  works  of  Braid,  Char- 
cot, Liebault,  Bernheim,  Forel,  Vogt,  Breuer  and  Freud, 
Schrenck-Notzing,  Prince,  Bechterew,  Janet,  Babinski, 
and  others,  are  well  known  to  the  student  in  abnormal 
psychology.  Recently,  however,  many  medical  men  of 
reputation,  such  as  Dubois,  Freud,  Prince,  Putnam,  Tay- 
lor, Waterman,  Donley,  and  many  others,  could  not  help 
being  impressed  by  the  practical  limitations  of  the  hyp- 
notic state.  Many  patients  refuse  to  submit  to  treat- 
ment, being  afraid  of  occult  influences.  Then  again  a 
great  number  of  patients  are  difficult  to  hypnotize. 
There  is  no  denying  the  fact  that  there  exists  a  strong 
feeling  of  distrust  among  many  conservative  men  wh< 
are  not  acquainted  with  the  amount  of  scientific  work 
that  has  been  lately  done  in  the  domain  of  abnormal  psy- 
chology. This  strong  feeling  against  the  use  of  th( 
hypnotic  state  as  a  therapeutic  agent  in  psychopathic 
diseases  is  unfortunately  often  found  among  many  rep-^ 
resentative  men  of  the  American  medical  profession. 

An  American  editor  of  a  well-known  American  medical 
journal  unhesitatingly  rejects  work  on  psychopathology 


106 


1 


VALUE  OF  THE  HYPNOIDAL  STATE      107 

and  psychotherapy.  The  editor  is  apparently  under  the 
impressicWT  that  he  is  keeping  up  the  high  standard  of 
American  medical  science, — that  papers,  disquisitions, 
and  discussions  on  diarrhea,  constipation,  enemas, 
eczema,  hemorrhoids,  and  cognate  scientific  investiga- 
tions are  essentially  valuable,  dignified,  and  suitable  to 
the  mind  and  needs  of  the  medical  reader.  In  Germany, 
France,  Italy,  Austria,  Russia,  work  in  abnormal  psy- 
chology has  long  ago  gained  recognition  as  a  science  of 
theoretical  and  practical  importance  to  the  physician  and 
even  to  the  lawyer,  while  in  the  United  States  conserva- 
tism in  regard  to  abnormal  psychology  is  still  paraded 
as  a  badge  of  orthodox  medical  respectability.  The  op« 
position  to  psychopathology  is  manifest,  when  it  comes 
to  the  use  of  the  hypnotic  state. 

Since  hypnosis  meets  with  so  much  opposition  the 
question  naturally  arises, —  Is  it  possible  to  affect  and 
modify  pathological  mental  states  outside  hypnosis? 
The  problem  is  practical  and  requires  a  solution.  In 
"  The  Psychology  of  Suggestion  "  I  pointed  out  on  the 
strength  of  a  number  of  experiments  that  suggestibility 
can  also  be  induced  in  the  fformal  waking  state.  I  have 
also  shown  that  among  the  conditions  of  normal  and  ab- 
normal suggestibility  monotony  and  limitation  of  activity 
play  an  important  role.  Any  arrangement  tending  to 
produce  monotony  and  limitation  of  voluntary  activity 
brings  about  a  state  of  suggestibility  termed  by  me 
subwaking  or  hypnoidal,  a  state  in  which  mental  life  can 
be  affected  with  ease.  The  induction  of  the  state  is 
termed  hypnoidization. 

In  the  hypnoidal  state  consciousness  becomes  some- 
what vaguer  than  in  the  waking  condition;  memory  is 
more  diffused,  so  that  experiences  apparently  long  forgot- 
ten come  in  bits  and  scraps  to  the  foreground  of  con- 


108  PSYCHOTHERAPEUTICS 

sciousness.  Emotional  excitement  subsides,  -voluntary 
activity  is  changed  to  passivity,  and  suggestions  meet 
with  little  resistance.  The  subwaking  state  is  above  all 
a  rest-state,  a  state  of  physical  and  mental  relaxation. 

The  favorable  therapeutic  results  obtained  by  me  led 
to  a  closer  study  of  what  I,  some  thirteen  years  ago,  re- 
garded as  a  peculiar  mental  condition.  The  subwaking 
or  hypnoidal  state  is  essentially  an  intermediate  state 
belonging  to  the  borderland  of  mental  life.  On  the  one 
hand  the  hypnoidal  state  closely  touches  on  the  waking 
state,  on  the  other  it  merges  into  hypnosis  and  sleep, 
A  close  study  of  the  subwaking  state  shows  that  it  differs 
from  the  hypnotic  state  proper  and  that  it  cannot  be 
identified  with  light  hypnosis.  In  my  years  of  study  of 
patients  and  subjects  I  have  observed  the  presence  of  the 
subwaking  state  before  the  development  of  hypnosis  and 
also  before  the  oncome  of  sleep.  When  again  sleep  and 
hypnosis  pass  into  waking,  the  hypnoidal  state  reap- 
pears. The  hypnoidal  state  may  therefore  be  regarded 
as  a  transitional,  intermediate  state. 

The  subwaking  state  may  be  said  to  partake  not  only 
of  the  nature  of  waking  and  sleep,  but  also  to  possess 
some  characteristics  of  hypnosis,  namely  suggestibility. 
It  is  clear  that  from  the  character  of  its  mixed  symp- 
tomatology the  hypnoidal  state  is  variable  and  unstable. 
The  subwaking  state  should,  in  fact,  be  regarded  as  an 
equivalent  of  sleep.  Like  sleep  the  hypnoidal  state  has 
many  levels  of  depth.  It  differs,  however,  from  sleep 
by  the  rapidity  of  its  oscillations  from  level  to  level.  In 
the  experiments  of  various  investigators  sleep  is  found 
to  be  represented  by  a  rapidly  rising  curve  during  the 
first  couple  of  hours,  and  by  a  gradually  descending  curve 
during  the  rest  of  the  hours  of  sleep.  No  such  regularity 
of  curve  can  be  observed  in  the  subwaking  state.  The 
depth  of  the  hypnoidal  state  changes  very  rapidly  and 


VALUE  OF  THE  HYPNOIDAL  STATE      109 

with  it  the  passive  condition  and  suggestibility  of  the 
patient. 

Thus  far  the  work  was  confined  to  observations  and 
experimentation  on  human  subjects  and  patients,  both 
from  a  theoretical  and  practical  therapeutic  standpoint. 
Recently,  however,  I  undertook  at  the  physiological 
laboratory  of  Harvard  Medical  School,  and  also  in  my 
own  psychopathological  laboratory,  a  series  of  experi- 
ments on  the  manifestations  of  sleep  in  the  ascending 
scale  of  animal  life, —  from  the  frog  and  guinea  pig,  the 
cat,  the  dog,  to  the  infant  and  adult. ^  The  experiments 
prove  that  the  hypnoidal  state  is  by  no  means  confined  to 
man,  but  is  also  present  in  the  lower  stages  of  animal 
life.  Furthermore,  the  experiments  clearly  show  that 
the  further  down  we  descend  in  the  scale  of  animal  life, 
the  more  prominent,  the  more  essential  does  the  subwak- 
ing state  become.  From  the  facts  one  is  forced  to  come 
to  the  conclusion  that  the  hypnoidal  state  is  the  primitive 
rest-state  out  of  which  sleep  has  arisen  in  the  later  stages 
of  evolution.  Sleep  and  hypnosis  have  taken  their  origin 
in  the  hypnoidal  state;  both  hypnosis  and  sleep  are 
highly  differentiated  states  and  have  become  evolved  out 
of  the  primitive,  undifferentiated,  subwaking  state,  which 
is  the  rest-state,  still  characteristic  of  the  lowly  organ- 
ized forms  of  animal  life.  In  short,  we  may  say  that 
the  hypnoidal  state  is  the  primordial  sleep-state.  In 
man  the  subwaking  state  is  but  in  a  rudimentary  condi- 
tion,—  it  has  shrunk  to  an  abortive,  transitory,  momen- 
tary stage  in  the  alternation  of  waking  and  sleep. 

While  in  the  hypnoidal  state  the  patient's  consciousness 
keeps  on  fluctuating  from  moment  to  moment,  now  fall- 
ing deeply  into  a  subconscious  state  in  which  outlived 
experiences  are  easily  aroused,  and  now  again  rising  to 

1  Sidis :    An  Experimental  Study  of  Sleep,  Joubnal  of  Abkob- 
MAL  Psychology,  1908. 


110  PSYCHOTHERAPEUTICS 

the  level  of  waking  consciousness.  The  experiences  come 
often  in  fragments  which  gradually  coalesce  and  form  a 
connected  series  of  interrelated  systems,  apparently  long 
gone  and  forgotten.  The  recognition  is  fresh,  vivid,  in- 
stinct with  life,  as  if  the  experiences  had  occurred  the 
day  before.  The  revived  experiences  are  in  many  cases 
confirmed  by  some  relative  or  intimate  friend.  This  char- 
acteristic of  getting  access  to  subconscious  experiences 
lost  to  the  patient's  personal  consciousness  is  what  makes 
the  hypnoidal  state  such  a  valuable  instrument  in  the 
tracing  of  the  origin  and  development  of  the  symptoms 
of  the  psychopathic  malady.  Important,  however,  as 
the  following-up  of  the  history  or  of  the  psychogenesis 
of  the  symptoms  may  be,  both  to  the  physician  and  to 
the  patient,  for  an  intelligent  and  scientific  comprehen- 
sion of  the  case,  it  does  not  cure^  as  some  are  apt  to 
claim,  the  psychopathic  malady.  The  value  of  tracing 
the  growth  of  the  disease  to  its  very  germs  lies  entirely 
in  the  insight  gained  into  the  nature  of  the  symptom-com- 
plex. The  tracing  of  the  psychogenesis  has  no  special 
therapeutic  virtues,  as  the  Germans  claim,  but,  like  all 
theoretical  knowledge,  is  of  the  utmost  importance  for  a 
clear  understanding  of  the  causation  of  the  psychopathic 
state,  thus  helping  materially  in  the  treatment  of  the 
case.  The  information  of  the  psychogenesis  given  to 
the  patient  is  valuable  only  in  so  far  as  by  a  systematic 
course  of  direct  and  indirect  suggestion,  by  mediate  asso- 
ciative and  immediate  associative  suggestion,  by  substi- 
tution, disintegration,  and  synthesis,  both  in  the  waking 
and  the  hypnoidal  states,  we  help  to  transform  the  asso- 
ciative course  and  emotional  tone  of  the  patient's  mental 
life.^  The  treatment  is  a  highly  complex  process  of  dis- 
integration and  integration  of  mental  systems. 

From  a  practical  standpoint  the  therapeutic  value  of 

2  Sidis :     Psychopathological     Research ;     Multiple     Personalityi 
Psychology  of  Suggestion. 


VALUE  OF  THE  HYPNOIDAL  STATE   111 

the  hypnoidal  state  is  by  far  the  most  important.  Now 
as  we  have  pointed  out,  our  experiments  on  sleep  have 
revealed  the  significant  fact  that  the  hypnoidal  state  is 
the  primordial  rest-state, —  sleep  is  but  a  derivative  form 
of  rest.  In  many  forms  of  diseases,  especially  nutri- 
tional, it  is  often  advisable  to  revert  to  a  more  simple 
and  more  primitive  form  of  nutrition.  Similarly  in  psy- 
chopathic maladies  a  reversion  to  a  simple  form  of  rest- 
state  proves  to  be  of  material  help  to  the  patient.  In 
plunging  the  patient  into  the  subwaking,  hypnoidal  state 
we  have  him  revert  to  a  primitive  rest-state  with  its  con- 
sequent beneficial  results.  The  suggestibility  of  the  hyp- 
noidal statey  if  skilfully  handled^  increases  the  therapeutic 
efficacy  of  the  hypnoidal  subwaking  state.  Relaxation 
of  nervous  strain,  rest  from  worry,  abatement  of  emo- 
tional excitement  are  known  to  be  of  great  help  in  the 
treatment  of  nervous  troubles  of  the  neurasthenic  or  of 
the  more  fashionable  psychasthenic.  We  find  something 
similar  in  the  treatment  of  psychopathic  diseases  by 
means  of  the  agency  of  the  hypnoidal  state  the  thera- 
peutic eflScacy  of  which  is  all  the  more  heightened  by  the 
presence  of  the  trait  of  suggestibility.  Most  important, 
however,  is  the  access  gained  through  the  agency  of  the 
hypnoidal  state  to  the  stores  of  potential  subconscious 
reserve-energy,  which,  by  a  liberation  of  energy,  bring 
about  a  reassociation  and  synthesis  of  the  dissociated 
mental  systems  underlying  the  symptoms  of  the  disease. 
The  therapeutic  value  of  the  hypnoidal  state  consists  in 
the  liberation  of  reserve  energy  requisite  for  the  syn- 
thesis of  the  dissociated  systems. 

The  theory  of  reserve  energy  is  of  the  utmost  impor- 
tance to  abnormal  psychology.  The  theory  was  ad- 
vanced independently  by  Prof.  James  ^  and  myself,^  and 

3  James:    The   Energies   of  Men,  Philosophical  Review,   1907. 
4Sidis:     Studies  in  Psychopathology,  Ch.  xiv.  The  Principle  of 
Reserve  Energy,  B.  M.  fJ.  J..  1907. 


112  PSYCHOTHERAPEUTICS 

seems  to  me  to  form  the  very  foundation  of  psycho- 
pathology  and  psychotherapeutics.  It  is  by  no  means 
easy  to  present  adequately  the  principle  of  reserve  en- 
ergy in  this  brief  paper.  The  principle  is  based  on  a 
broad  generalization  of  facts,  psychological,  physio- 
logical, and  biological,  namely,  that  far  less  energy  is 
utilized  by  the  individual  than  there  is  actually  at  his 
disposal.  In  fact,  but  a  very  small  fraction  of  the  total 
amount  of  energy  possessed  by  the  organism  is  used  in 
its  relation  with  the  ordinary  stimuli  of  its  environment. 
The  energy  in  use  may  be  regarded  as  the  kinetic  or 
circulating  energy,  while  the  energy  stored  away  is  the 
potential  reserve  energy.  There  must  always  be  a  re- 
serve supply  of  energy  requisite  for  unusual  reactions 
in  emergency  cases.  Those  organisms  survive  which 
have  the  greatest  amount  of  reserve  energy,  just  as  those 
countries  are  stronger  and  victorious  in  the  world-mar- 
ket which  possess  the  largest  amount  of  reserve  capital 
to  draw  upon  in  critical  periods. 

As  life  becomes  more  complex  inhibitions  increase, — 
the  thresholds  of  stimulations  of  a  complex  system  rise 
in  proportion  to  its  complexity.  With  the  rise  of  evo- 
lution there  is  a  tendency  to  increase  of  inhibitions  with 
a  consequent  lock-up  of  energy  which  becomes  reserve. 
Now  there  are  occasions  in  the  life  of  the  individual,  un- 
der the  influence  of  training  and  emotional  trauma,  when 
the  inhibitions  become  unusually  intense  and  tend  to 
smother  the  personality  which  is  weakened,  impoverished 
in  its  reactions,  and  is  unable  to  respond  freely  to  the 
stimuli  of  its  environment.  The  inhibited  system  becomes 
inactive  and  may  be  regarded  as  dissociated  from  the 
cycle  of  life.  In  case  of  an  emotional  trauma  there  is 
often  a  breach  in  continuity  of  association,  the  affected 
system  becomes  dissociated  from  the  rest  of  mental  life, 
and  is  like  a  splinter  in  the  flesh  of  the  individuality.     Its 


i 


VALUE  OF  THE  HYPNOIDAL  STATE   113 

own  threshold  when  tapped  may  be  very  low,  but  is  not 
directly  accessible  through  the  mediacy  of  other  sys- 
tems. On  that  account  its  threshold  appears  unusually 
or  pathologically  high.  When  the  inhibitions  are  very 
high  they  must  be  removed.  This  removal  of  inhibitions 
brings  about  an  access  to  the  accumulated  energy  of  the 
inhibited  system.  In  case  of  disjunction  or  break  of 
continuity  we  must  stimulate  the  reserve  dormant  energy 
of  the  systems  and  thus  assist  the  process  of  repair  and 
bridge  the  breach  of  associative  continuity.  A  new 
fresh  active  life  opens  to  the  patient.  He  becomes  a 
different,  a  "  reformed  "  personality,  free  and  cheerful, 
with  an  overflow  of  energy. 

To  quote  from  a  former  work  of  mine :  ^  ^ 

"  The  thresholds  of  our  psychophysiological  systems  ■ 
are  usually  raised,  mental  activity  working  in  the  course 
of  its  development  and  growth  of  associative  processes 
under  ever  increasing  inhibitions  with  ever  higher  thresh- 
olds. .  .  .  On  account  of  the  high  thresholds  and  in- 
hibitions not  the  whole  amount  of  the  psychophysiolog- 
ical energy  possessed  by  the  system  is  manifested;  in 
fact,  but  a  very  small  portion  is  displayed  in  response 
to  stimuli  coming  from  the  habitual  environment.  What 
becomes  of  the  rest  of  the  unused  energy.'*  It  is  storedy 
reserve  energy, 

"  Biologically  regarded,  we  can  well  see  the  importance 
of  such  stored  or  reserve  energy.  In  the  struggle  for  ex- 
istence, the  organism  whose  energies  are  economically 
used  and  well  guarded  against  waste  will  meet  with  better 
success  in  the  process  of  survival  of  the  fittest,  or  will 
have  better  chances  in  the  process  of  natural  selection. 
The  high  thresholds  and  inhibitions  will  prevent  hasty 
and  harmful  reactions  as  well  as  useless  waste  of  energy, 
unnecessary  fatigue,  and  states  of  helpless  exhaustion. 
5  studies  in  Psychopathology,  B.  M.  S.  J.,  1907. 


114  PSYCHOTHERAPEUTICS 

Moreover,  natural  selection  will  favor  organisms  with 
greater  stores  of  reserve  energy  which  could  be  put  forth 
under  critical  conditions  of  life.  In  fact,  the  higher  the 
organization  of  the  individual,  the  more  varied  and  com- 
plex the  external  environment,  the  more  valuable  and 
even  indispensable  will  such  a  store  of  reserve  energy 
prove  to  be.  (/  \ 

"  The  course  of  civilization  and  education,  by  contin- 
uously raising  the  thresholds  and  inhibitions,  follows  the 
line  of  natural  selection  and  keeps  on  increasing  the  dis- 
posable store  of  potential,  subconscious  or  reserve  energy 
both  in  the  individual  and  the  race.  It  is  in  this  forma- 
tion of  an  ever-greater  and  richer  store  of  disposable, 
but  well-guarded,  reserve  energy,  that  lies  the  superiority 
of  the  educated  over  the  uneducated  and  the  supremacy 
of  the  higher  over  the  lower  races. 

"  Civilization  and  education  are  processes  of  economy 
of  psycho-neural  force,  savings  of  mental  energy.  But 
what  society  is  doing  in  a  feeble  way  natural  selection 
has  done  far  more  effectively.  What  education  and  civ- 
ilization are  doing  now  on  a  small  scale  and  for  a  brief 
period  of  time  the  process  of  survival  of  the  fittest  in  the 
ever-raging  struggle  for  existence  has  done  for  ages  on 
a  large  scale.  We  should,  therefore,  expect  that  the  nat- 
ural reserve  energy  would  far  exceed  that  of  the  culti- 
vated one. 

"  In  the  treatment  of  the  phenomena  of  psycho-physio- 
logical dissociation,  in  the  protean  symptoms  of  nervous 
and  mental  exhaustion  we  should  not  forget  this  bio- 
logical principle  of  reserve  energy  and  should  make  at- 
tempts to  use  it.  In  many  cases  the  inhibitions  become 
too  heavy  and  the  thresholds  too  high.  We  must  loosen 
the  grip  of  some  of  the  inhibitions  and  lower  the  thres- 
holds, thus  utilizing  a  fresh  supply  of  reserve  energy." 

A  similar  train  of  thought  was  developed  by  Dr.  S.  J. 


VALUE  OF  THE  HYPNOIDAL  STATE      115 

Meltzer  in  his  excellent  paper  on  "  The  Factors  of  Safety 
in  Animal  Structure  and  Animal  Economy."  ^  By  a 
striking  series  of  instructive  facts  Dr.  Meltzer  points  out 
that  "  All  organs  of  the  body  are  built  on  the  plan  of  . 
superabundance  of  structure  and  energy."  I  cannot  re- 
sist the  temptation  of  quoting  Dr.  Meltzer's  conclusions 
at  some  length  as  they  so  clearly  elucidate  our  principle 
of  reserve  energy  which  is  all  the  more  valuable  as  Dr. 
Meltzer  has  formulated  it  independently  on  widely  differ^ 
ent  grounds.  "  Of  the  supplies  of  energy  to  the  animal 
we  see  that  oxygen  is  luxuriously  supplied.  The  supply  i 
of  carbohydrates  and  fats  is  apparently  large  enough  to  j 
keep  up  a  steady  luxurious  surplus.  .  .  .  The  liberal  in-? 
gestion  of  proteid  might  be  another  instance  of  the  prin-; 
ciple  of  abundance  ruling  the  structure  and  energies  of 
the  animal  body.  There  is,  however,  a  theory  that  in 
just  this  single  instance  the  minimum  is  meant  by  nature 
to  be  also  the  optimum.  But  it  is  a  theory  for  the  sup- 
port of  which  there  is  not  a  single  fact.  On  the  con- 
trary, some  facts  seem  to  indicate  that  Nature  meant 
differently.  Such  facts  are,  for  instance,  the  abundance 
of  proteolytic  enzymes  in  the  digestive  canal  and  the 
great  capacity  of  the  canal  for  absorption  of  proteids. 
Then  there  is  the  fact  that  proteid  material  is  stored 
away  for  use  in  emergencies  just  as  carbohydrates  and 
fats  are  stored  away.  In  starvation  nitrogenous  prod- 
ucts continue  to  be  eliminated  in  the  urine  which,  accord- 
ing to  Folin,  are  derived  from  exogenous  sources,  that 
is  from  ingested  proteid  and  not  from  broken  down  or- 
gan tissues.  An  interesting  example  of  storing  away  of 
proteid  for  future  use  is  seen  in  the  muscles  of  the  salmon 
before  they  leave  the  sea  for  the  river  to  spawn.  Ac- 
cording to  Mescher  the  muscles  are  then  large  and  their 
productive  organs  are  small.  In  the  river  where  the 
6  Science,  1907. 


116  PSYCHOTHERAPEUTICS 

animals  have  to  starve,  the  reproductive  organs  becom 
large,  while  the  muscles  waste  away.  Here  in  time  o 
affluence  the  muscles  store  up  nutritive  material  for  th 
purpose  of  maintaining  the  life  of  the  animal  during 
starvation  and  of  assisting  in  the  function  of  reproduc 
tion.  This  instance  seems  to  be  quite  a  good  illustratioi 
of  the  role  which  the  factor  of  safety  plays  also  in  th( 
function  of  the  supply  of  the  body  with  proteid  food 
The  storing  away  of  proteid  like  the  storing  away  oj 
glycogen  and  fat  for  the  use  in  expected  and  unexpecte 
exceptional  conditions  is  exactly  like  the  superabundance 
of  tissue  in  an  organ  of  animal  or  like  an  extra  beam 
the  support  of  a  building  or  a  bridge, —  a  factor  of 
safety. 

"  It  seems  to  me  that  the  factors  of  safety  have  an  im- 
portant place  in  the  process  of  natural  selection.  Thos 
species  which  are  provided  with  an  abundance  of  usefu 
structure  and  energy  and  are  prepared  to  meet  many 
emergencies  are  best  fitted  to  survive  in  the  struggle  foi 
existence." 

The  hypnoidal  state  is  essentially  a  rest-state  charac 
terized  by  anabolic  activity.  There  is  a  restitution  of 
spent  energy;  inhibitions  become  removed  and  access  is 
gained  to  what  Dr.  Prince  so  aptly  describes  as  "  dor- 
mant "  systems  or  complexes.  The  awakened  "  dor- 
mant "  complex  systems  bring  with  them  a  new  feeling- 
tone,  a  fresh  emotional  energy  resulting  in  an  almost 
complete  transformation  of  personality. 

As  an  illustration  of  the  transformation  effected  I 
take  at  random  the  following  extracts  from  some  of  the 
letters  written  to  me  by  patients  who  have  experienced 
this  welling  up  of  reserve  energy: 

"  Indeed  were  I  to  fill  this  entire  sheet  with  expression 
of  the  gratitude  which  wells  up  from  my  inmost  heart  i 
would  be  only  a  beginning  of  what  I  feel.     Surely  the 


i 

I 


VALUE  OF  THE  HYPNOIDAL  STATE   117 

darkness  of  the  world  has  been  dispelled  since  this  new 
light  has  illuminated  my  soul,  and  I  feel  that  this  won- 
drous light  will  never  fail  me.  It  were  vain  to  attempt 
to  thank  you  for  this  wonderful  transformation." 

Another  letter  reads :  "  You  will  be  glad  to  know  that 
all  is  well  with  me.  Life  is  one  happy  day,  I  am  a  marvel 
to  my  friends  in  the  way  of  happiness  and  cheer.  I  have 
to  confess  that  I  feel  almost  wicked  to  be  so  happy." 

Another  letter  runs  as  follows :  "  Next  to  the  gladness 
in  my  own  restoration,  I  am  rejoiced  at  the  wonderful 
transformation  that  has  come  to  my  dear  friend  T.  from 
your  marvelous  treatment.  She  writes  me  most  enthu- 
siastically of  her  steady  and  sure  progress  toward  the 
goal  of  perfect  health,  of  her  strength  to  take  up  the 
home  duties  which  had  been  so  burdensome  and  which  she 
now  finds  a  delight  in  the  doing  of  them,  and  of  her 
husband's  and  friends'  joy  in  the  transformation  that 
has  been  wrought  in  her." 

Dr.  Prince  in  his  "  Unconscious  "  '^   gives  an  extract 
of  a  patient's  letter  which  tells  of  a  similar  transforma-  \ 
tion  and  awakening  of  dormant  reserve  energy.     "  Some-    j 
thing  has  happened  to  me  —  I  have  a  new  point  of  view. 
I  don't  know  what  has  changed  me  all  at  once,  it  is  as  if 
scales  had  fallen  from  my  eyes;  I  see  things  differently 
—  you  have  given  me  life  and  you  have  given  me  some-  / 
thing  to  fill  it  with.     I  owe  you  what  is  worth  far  more 
than  life  itself,  namely  the  desire  to  live." 

Those  extracts  are  typical  of  many  others  and  clearly 
show  the  enjoyment  of  new  strength  and  powers  until 
now  unknown  to  the  patient.  Fresh  levels  of  reserve  en- 
ergy have  been  tapped  and  have  become  available  in  an 
hour  of  dire  need.  The  patient  has  light  and  strength 
where  there  were  darkness  and  depression.  We  are  con- 
fronted here  with  the  important  phenomenon  of  liberation 
7  Journal  of  Abnormal  Psychology,  1909. 


118  PSYCHOTHERAPEUTICS 

of  dormant  reserve  energy.  The  patient  feels  the  flood 
of  fresh  energies  as  a  "  marvelous  transformation,"  as  a 
"  new  light,"  as  a  "  new  life,"  as  "  something  worth  far 
more  than  life  itself." 

The  hypnoidal  state  helps  us  to  reach  the  inaccessible 
regions  of  dormant  energy,  it  helps  to  break  down  in- 
hibitions, liberate  reserve  energies,  and  repair  the 
breaches  of  mental  activity.  The  painful  systems  be- 
come dissociated,  disintegrated  and  again  transformed, 
reformed,  and  reintegrated  into  new  systems  full  of  en- 
ergy and  joy  of  life. 

It  is  quite  probable  that  Weir  Mitchell's  rest-cure  has 
derived  some  therapeutic  value  from  the  empirical  use  of 
the  subwaking  hypnoidal  rest-state.  Similarly  it  is 
highly  probable  that  Freud's  success  in  the  treatment  of 
psychopathic  cases  is  not  so  much  due  to  "  psycho-analy- 
sis," as  to  the  unconscious  use  of  the  hypnoidal  state. 
The  use  of  the  hypnoidal  state  or  hypnoidization  has 
been  recently  employed  with  great  success  by  other  in- 
vestigators, among  whom  I  may  mention  Dr.  John  E. 
Donley,  who  has  made  a  valuable  contribution  to  the 
therapeutic  aspect  of  the  hypnoidal  state.^  I  am  firmly 
convinced  that  the  hypnoidal  state,  if  rightly  and  intelli- 
gently utilized,  will  prove  an  important  factor  in  the 
domain  of  psychopathology  and  psychotherapeutics. 

Now  as  to  the  method  of  hypnoidization.  There  is 
nothing  rigid  about  the  method, —  it  admits  of  many 
modifications.  The  principal  object  consists  in  bring- 
ing about  the  conditions  of  monotony  and  limitation  of 
voluntary  movements  requisite  for  normal  and  abnormal 
suggestibility.  The  patient  is  put  in  a  relaxed,  recum- 
bent position ;  he  is  asked  to  put  himself  into  as  com- 
fortable a  position  as  possible,  close  his  eyes,  and  attend 

8  The  Clinical   use   of   Hypnoidization,   Journal   of   Abnormal 
Psychology,  1908. 


I 


VALUE  OF  THE  HYPNOIDAL  STATE      119 

to  some  monotonous  stimulus  such  as  the  regular  beats 
of  a  metronome  or  the  buzzing  of  an  inductorium. 
Gentle  massage  and  a  warm  bath  may  be  of  material  help 
in  excitable  cases.  Exercise,  fatigue  both  physical  and 
mental,  predisposition  to  sleep,  and  the  late  hours  of 
night  or  the  small  hours  of  morning,  are  favorable  con- 
ditions. When  respiration  and  pulse  become  reduced, 
sensory-motor  reaction  diminished,  sensory  hypoesthesia 
becoming  occasionally  hyperesthesia,  with  occasional  dis- 
turbances of  pulse  and  respiration,  with  sudden  appar- 
ently unaccountable  starts,  with  tendencies  of  retention  of 
position  of  limbs,  and  now  and  then  with  a  slight  tendency 
to  resist  actively  any  change  of  posture  of  limbs  or  of 
body  without  the  actual  presence  of  catalepsy,  the  whole 
feeling  tone  becoming  one  of  acquiescence  and  indiffer- 
ence, while  memory  with  amnesic  gaps  begins  to  find  the 
lost  links  and  even  to  become  hypermnesic, —  when  we  ob- 
serve all  those  symptoms  we  know  we  have  before  us  the 
subconscious  hypnoidal  state.^  Pneumographic  tracings 
taken  at  the  same  time  help  to  detect  the  state,  charac- 
teristic by  the  numerous  transient  changes  and  the 
various  oscillations  of  depth  of  level  which  take  place  in 
this  unstable  subwaking  state,  intermediate  as  it  is  be- 
tween the  waking  state  on  the  one  hand,  sleep  and  hyp- 
nosis on  the  other. 

From  this  general  discussion  about  the  nature  of  the 
hypnoidal  state  and  the  methods  of  its  induction  we  may 
now  turn  to  a  brief  review  of  some  of  the  cases  treated  by 
hypnoidization.  The  tracing  of  the  growth  and  develop- 
ment of  the  various  symptoms  by  means  of  the  memories 
restored  in  the  hypnoidal  state  is  here  omitted,  as  the 

0  "  The  subconscious,"  notwithstanding  the  ill-based  attacks  now    • 
fashionable  among  some  psychologists,  forms  the  very  foundation  of    \ 
psychopathology.     The    subconscious    is    as    vital    and    essential    in    • 
psychopathology  as  "ether"  is  in  physics.    I  shall  discuss  this  sub- 
ject in  its  proper  place.  / 


120  PSYCHOTHERAPEUTICS 

p 

object  of  the  present  paper  is  not  the  study  of  the  causa- 
tion and  origin  of  the  psychopathic  systems  or  "  com- 
plexes," but  rather  their  reassociation  and  cure  effected 
by  the  reserve  energies  liberated  in  the  hypnoidal  state. 
I  give  cases  of  partial  as  well  as  complete  success  so  as 
to  give  the  reader  a  more  or  less  adequate  notion  of  the 
therapeutic  value  of  the  treatment.  Cases  of  partial 
success  are  presented  first. 

I.  Miss  P.  R.  Age  23.  American.  Mother  is  very 
nervous.  Sister  is  "  high  strung."  Father  is  well. 
When  young,  patient  was  regarded  as  sensitive.  Her 
present  trouble  began  three  years  ago.  She  suffers  from 
digestive  disturbances,  dizziness,  circulatory  irregulari- 
ties, numbness  in  hands  and  legs,  and  especially  from 
continuous  feeling  of  fatigue.  Her  sleep  is  restless,  she 
dreams  a  good  deal.  Attention  is  good,  but  her  mental 
state  is  one  of  indecision.  If  left  to  herself,  she  would 
remain  in  the  same  place.  To  make  a  change  in  her  sur- 
roundings is  hard  and  painful  to  her.  The  fear  of  meet- 
ing people  and  specially  strangers  is  quite  intense;  in 
fact,  it  constitutes  her  central  obsession.  At  the  age  of 
eighteen  she  fell  in  love  with  a  young  man  to  whom  she 
became  engaged.  A  year  later  the  engagement  was 
broken  off  under  very  distressing  circumstances.  Since 
then  the  present  condition  has  gradually  developed. 
The  patient  was  in  a  chronic  state  of  mental  depression 
and  was  not  unaware  of  the  real  origin  of  her  trouble, 
but  the  awareness  was  vague,  often  falling  below  the  mar- 
gin of  clear  consciousness. 

The  patient  expected  to  be  hypnotized,  but  she  could 
not  go  into  hypnosis.  After  a  few  trials  at  hypnotiza- 
tion  the  hypnoidal  state  was  used.  At  first  the  hyp- 
noidal  state  was  brief  in  duration,  but  with  its  repetition 
it  became  prolonged  and  deepened  with  gradually  in- 
creasing beneficial  effects.     The  patient  was  but  three 


VALUE  OF  THE  HYPNOIDAL  STATE     121 

weeks   under  my   care.     She  felt  greatly   improved   and 
returned  home  before  the  recovery  was  made  complete. 

II.  Mr.  A.  C.  Actor.  Age  47.  American.  There 
are  no  special  diseases  in  the  family  except  "  nervous- 
ness." The  patient  is  imaginative  and  emotional. 
When  about  the  age  of  ten  his  grandfather  gave  him 
Faust  to  read.  Since  then  he  has  been  troubled  with  the 
insistent  idea  of  having  sold  his  soul  to  Satan.  In  his 
childhood  he  was  very  religious, —  prayed  much,  was 
afraid  of  sins,  and  suffered  from  nightmares.  About 
fifteen  years  ago  had  syphilis,  for  which  he  was  treated 
for  a  period  of  two  years.  Up  to  the  age  of  32  patient 
led  a  gay  life.  Seven  years  ago  he  suddenly  felt  that 
"  something  snapped  in  his  head  "  and  he  became  greatly 
frightened.  He  thought  it  was  paresis  or  tabes,  "  as  so 
many  actors  suffer  from  those  diseases."  This  fright, 
however,  soon  wore  off.  A  month  later,  after  a  strenuous 
and  fatiguing  series  of  plays,  he  suddenly  woke  up  in 
the  middle  of  the  night  with  the  idea  of  paresis  and  in- 
tense fear.  The  overconscientiousness  and  fear  of  sin 
characteristic  of  his  childhood  and  boyhood  have  now 
reappeared,  and  he  is  obsessed  by  the  fear  of  sin,  decep- 
tion, blasphemy.  He  suffers  from  vague  pains  all  over 
the  body  and  from  digestive  disturbances,  but  he  is  spe- 
cially obsessed  by  the  fear  of  parasyphilitic  diseases, 
tabes  and  paresis,  the  symptoms  of  which  are  reflected  in 
his  attacks. 

In  the  hypnoidal  state  he  became  quieted,  much  of 
the  fear  and  depression  was  gone.  In  addition  to  other 
information  obtained,  though  interesting  from  a  psycho- 
pathological  standpoint,  space  does  not  permit  to  give 
here,  it  was  found  that  the  last  attack  was  occasioned  by 
a  long  visit  to  a  friend  of  his,  also  an  actor,  who  suf- 
fered from  gastric  crises  of  tabes.     A  series   of  treat- 


in  PSYCHOTHERAPEUTICS 


ments  by  hjpnoidization  improved  considerably  the  pa 
tient's  condition,  and  he  returned  to  his  occupation,  which 
he  could  not  possibly  give  up  for  any  length  of  time 

HI.  Mr.  C.  S.  Age  39.  Russian.  Builder.  Fathei 
died  of  apoplexy  at  the  age  of  72.  Mother  is  77j 
but  has  always  been  nervous.  Brothers  and  sisters 
are  well.  Patient  is  rather  undersized  and  weighs  ninety- 
seven  pounds.  He  is  very  emaciated,  looks  cachectic, 
suffers  from  anorexia,  nausea,  indigestion,  and  from 
vague  abdominal  pains.  Detailed  inquiry  into  the  pa- 
tient's sexual  life  disclosed  no  abnormality.  Anything! 
unpleasant  awakens  a  feeling  of  nausea.  This  can  b( 
traced  to  an  infectious  disease  from  which  the  patient 
suffered  some  twelve  years  ago.  He  was  frightened  over 
it  and  worried  about  the  consequences.  Nausea  and  vom- 
iting were  present  during  the  course  of  the  disease  and 
persisted  afterwards.  The  patient  is  introspective  and 
suggestible  in  regard  to  sickness.  If  any  of  the  family 
happen  to  have  any  trouble,  he  is  sure  to  fall  sick  with 
the  same  symptoms.  Thus  about  two  months  ago  the 
patient's  mother  fell  and  broke  her  left  arm,  he,  too,  soon 
began  to  feel  pain  in  the  left  arm,  for  which  he  had  to 
be  treated.  Every  new  moon  he  experiences  intestinal 
disturbances,  because  about  that  time,  in  his  childhood, 
his  mother  used  to  administer  to  him  a  purgative.  J 

Put  into  the  hypnoidal  state  patient  felt  much  relieved.! 
The  beneficial  results  of  the  treatment  became  manifested 
at  the  end  of  a  few  weeks. 


I 


IV.  Mr.  M.  G.  Irish.  Age  38.  Married.  Occupa- 
tion, liquor  dealer.  Father  alive  and  well.  Mother  died 
of  pneumonia  at  the  age  of  forty.  Brother  and  sister 
died  of  some  obscure  form  of  "  heart  trouble."  Physical 
condition  is  good.     Patient  has  no  appetite,  worries,  has 


VALUE  OF  THE  HYPNOIDAL  STATE      123 

no  confidence  in  himself.  He  is  extremely  methodical, 
things  must  be  arranged  in  certain  order  or  he  feels  un- 
easy and  quite  unhappy.  Has  no  headaches,  but  suffers 
from  insomnia.  Does  not  drink,  but  smokes  excessively. 
Sexual  life  normal.  Has  been  sensitive  and  nervous  from 
his  very  childhood.  He  broods  much  over  his  incapacity 
of  spelling.  Has  been  lately  working  very  hard  on  a  new 
business  intrusted  to  his  care.  He  doubts  his  business 
capacities  and  fears  to  ruin  the  business.  He  became 
greatly  depressed  and  had  to  give  up  his  work  and  go 
to  the  country,  but  with  no  beneficial  results. 

The  patient  was  brought  to  me  in  a  state  of  deep  de- 
spondency, close  on  the  brink  of  suicide.  He  could  not 
be  hypnotized.  I  put  him  into  a  hypnoidal  state,  kept 
him  in  a  state  of  relaxation  for  fifteen  minutes.  When 
he  came  out  of  it  he  felt  "  a  little  better,  but  not  much." 
After  two  weeks'  treatment  the  patient  felt  so  far  im- 
proved that  I  advised  him  to  return  to  his  work,  while 
the  treatment  was  being  continued.  Gradually  his  de- 
spondency gave  way,  his  worries,  fears,  and  doubts  dis- 
appeared, and  confidence  in  himself  became  strengthened. 
Patient  declared  he  "  never  felt  so  well  before."  The 
treatment  covered  a  period  of  three  months.  It  is  now 
more  than  two  years,  the  patient  continues  to  be  in  ex- 
cellent condition. 

I  V.  Mrs.  J.  F.  Age  28.  American.  Married.  Fam- 
ily history  good.  For  many  years  patient  has  been 
suffering  from  severe  headaches,  backache,  general  fa- 
tigue, and  weakness  of  the  eyes  which  occasionally  be- 
came intolerably  painful.  The  headaches  became  some- 
times so  intense  that  the  patient  suffered  agonies.  The 
pains  extended  all  over  the  head  and  even  down  the  arms 
and  back.  There  were  present  sore  spots  in  the  back  of 
the  head,  the  pressure  on  which  somewhat  relieved  the 


IM  PSYCHOTHERAPEUTICS 

pain.  Various  pains  of  a  more  indefinable  character  were 
also  complained  of  in  the  right  ovarian  region,  pains 
which  increased  on  exercise.  The  patient  had  usually 
no  appetite,  nothing  tasted  well, —  there  was  some  un- 
pleasant odor  in  the  food;  nutrition  was  poor.  Occa- 
sionally she  suffered  from  bulimia  alternating  with 
anorexia.  The  sense  organs  were  hyperesthetic ;  field  of 
vision  was  normal.  The  heart  was  normal,  though  occa- 
sionally irregularity  of  heart-beat  could  be  observed,  due 
to  the  patient's  extreme  nervousness.  A  gynecologist 
diagnosed  salpingitis  and  advised  an  operation  on  ac- 
count of  adhesions  formed.  The  patient,  however,  re- 
fused to  be  operated  on,  and  the  family  physician  carried 
out  a  long  course  of  gynecological  treatment.  The  ocu- 
list treated  her  eyes,  and  after  a  long  examination  and 
treatment  fitted  her  with  glasses;  but  the  eyes  were  no 
better  and  the  headaches  were  as  severe  as  before. 

After  a  fair  trial  had  been  given  to  various  treatments 
I  had  to  resort  to  hypnoidization.  A  year's  treatment 
by  the  hypnoidal  state  made  the  symptoms  disappear. 
The  patient  gained  in  flesh  and  in  strength,  and  felt,  as 
she  put  it,  "  younger  than  ever." 

VI.  Miss  G.  A.  Age  55.  American.  Three  broth- 
ers died  of  various  forms  of  cardiac  affections. 
Father  died  of  pnemonia ;  mother  died  of  fatty  degenera- 
tion of  the  heart.  One  of  the  sisters  suffered  from 
akromegaly  and  died  of  heart  trouble.  There  are  his- 
tories of  tuberculosis  in  the  collateral  branches  of  the 
family.  Patient  looks  poorly  nourished,  her  appetite  is 
completely  gone.  She  suffers  from  insomnia,  headaches,  ^ 
backache,  general  diffused  pains  all  over  the  body;  com- 
plains of  lassitude  and  of  lack  of  interest  in  what  goes 
on  around  her.  She  feels  despondent  and  has  crying 
spells.     The  depression  reaches  such  an  acute  stage  that 


VALUE  OF  THE  HYPNOIDAL  STATE      125 

the  patient  is  afraid  of  losing  her  mind.  When  a  child 
she  suffered  from  pavor  nocturnus  and  when  about  the 
age  of  twelve  she  took  a  long  fatiguing  journey  which 
brought  on  such  a  state  of  exhaustion  that  on  her  return 
she  became  aphasic  and  hemiplcgic  and  was  confined  to 
bed  for  six  months.  The  present  condition  set  in  a  few 
years  ago, —  she  lost  the  sense  of  smell  and  of  taste, 
while  she  fell  into  a  state  of  deep  depression.  Neurolo- 
gists regarded  her  as  a  case  of  some  obscure  "  neurosis," 
obstinate  and  incurable. 

I  must  confess  that  when  I  undertook  the  case  I  did 
not  expect  any  favorable  results.  It  was  an  old, 
chronic,  insidious  case.  The  age  of  the  patient,  the  ap- 
parent obscurity  of  the  trouble,  as  well  as  the  family 
history  were  by  no  means  encouraging.  The  patient 
did  not  go  into  a  hypnotic  state  and  I  had  to  use  the 
hypnoidal  state.  The  first  couple  of  months  the  treat- 
ment dragged  along  indifferently.  All  I  could  then  say 
was  that  the  patient  did  not  get  worse  under  the  treat- 
ment. The  hypnoidal  state,  however,  gradually  ad- 
mitted me  into  the  patient's  early  history,  and  I  obtained 
important  clues  to  her  symptoms.  Here  comes  in  the 
value  of  a  knowledge  of  the  course  and  the  development 
of  the  malady  and  the  consequent  help  in  the  therapeutic 
treatment  of  the  dissociated  systems.  With  a  better  in- 
sight into  the  abnormal  psychology  of  the  case  the  hyp- 
noidal state  could  be  used  to  better  advantage.  The  pa- 
tient began  to  improve  rapidly  and  at  the  end  of  the 
fourth  month  of  treatment  by  hypnoidization  completely 
recovered.  It  is  now  more  than  four  years  since  the  end 
of  the  treatment,  and  I  may  say  that  the  patient  has  not 
had  a  single  relapse, —  she  continues  to  stay  well ;  she 
has  become  an  energetic  social  worker,  greatly  valued  for 
her  indomitable  energy  as  well  as  cheerfulness  of  mind. 
People  who  know  her  say  that  "  wherever  she  goes  she 


126  PSYCHOTHERAPEUTICS 

brings  sunshine  with  her."  A  new  life  was  awakened  in 
her.  The  subconscious  reserve  energy  which  has  re- 
mained dormant  in  her  for  so  many  years  has  become 
unlocked  and  utilized  in  her  ordinary  daily  life. 

VII.  Miss  A.  W.  Age  35.  Irish.  Housekeeper. 
Physical  condition  is  good.  Occasionally  suffers  from 
cephalalgia,  but  on  the  whole  headaches  do  not  trouble; 
her.  She  suffers  often  from  auditory  hallucinations, 
thinks  she  is  possessed  by  demons.  From  her  ninth  year 
she  had  hallucinations  of  spirit  voices  which  tell  her  veryi 
unpleasant  things.  The  auditory  hallucinations  are  ac- 
companied by  attacks  of  automatic  speech.  It  seems  to 
the  patient  as  if  another  being  forces  her  to  tell  what 
she  thinks.  It  is  on  that  account  that  she  shuns  hen 
friends  and  acquaintances.  Occasionally  she  has  visual 
hallucinations  of  angels  and  saints. 

It  would  take  too  much  space  to  give  an  account  of' 
this  interesting  case.  We  can  only  refer  here  to  this 
case  in  its  main  outlines.  Our  object  is  not  the  psycho- 
pathological,  but  the  psychotherapeutic  aspect  of  the  cases. 

The  patient  could  not  be  hypnotized,  but  she  v/ent 
easily  into  the  hypnoidal  state.  At  first  the  improve- 
ment was  rather  slight.  In  fact,  now  and  then  the  hal- 
lucinations and  the  automatic  speech  became  even  more 
frequent  and  more  annoying  than  before.  In  a  couple 
of  months,  however,  the  outlook  began  to  be  brighter,  the 
auditory  and  visual  hallucinations  began  to  give  way. 
The  automatic  speech  considerably  diminished,  and  after 
a  few  months  the  symptoms  completely  disappeared. 

In  the  control  of  alcoholism  the  treatment  by  hypnoi- 
dization  yields  extremely  satisfactory  results.  The  prin- 
ciple of  subconscious  reserve  energy  stands  out  clear  and 
distinct  in  such  cases.  We  shall  return  to  this  aspect 
of  psychotherapeutics  in  its   proper  place,   our   object 


VALUE  OF  THE  HYPNOIDAL  STATE      127 

lere  is  simply  to  bring  out  the  therapeutic  value  of  the 
hypnoidal  state. 

VII.  Mr.  G.  S.  American.  Single.  Age  37.  Fam- 
ily history  is  good, —  except  that  one  maternal  un- 
cle was  a  victim  of  drink  habit.  A  physical  examination 
shows  an  irregular  heart  due  to  nervousness,  excessive 
smoking.  Liver  is  enlarged  and  cirrhotic.  The  patient 
was  brought  to  me  just  after  a  debauch,  was  nervous, 
shaky,  with  quite  an  extensive  tremor  of  the  hands.  He 
began  to  drink  when  in  school  as  a  matter  of  boon  com- 
panionship and  has  since  become  addicted  to  drink.  He 
kept  at  it  regularly,  at  times  actually  soaking  in  alcohol. 
The  family  induced  him  to  try  the  treatment  of  various 
establishments  for  the  cure  of  alcoholics,  but  with  no  ap- 
preciable results.  As  soon  as  he  left  the  sanitarium  he 
immediately  went  off  on  a  debauch.  He  suffered  a  few 
times  from  severe  attacks  of  delirium  tremens.  The  pa- 
tient was  in  such  a  bad  state  that  he  wanted  his  share  of 
property  to  devote  the  remainder  of  his  life  to  drink. 

Under  a  rigorous  treatment  by  the  hypnoidal  state 
the  patient  ceased  drinking,  lost  all  craving  for  liquor. 
His  physical  and  mental  condition  grew  in  strength. 
After  a  few  months'  treatment  he  was  enabled  to  return 
to  his  business.  The  man  has  become  completely  re- 
formed. He  is  now  manifesting  an  intense  activity, 
great  devotion  to  and  steadiness  in  his  work.  No  one 
suspected  in  him  such  capacities  of  foresight  and  energy 
in  business  management.  New  stores  of  subconscious, 
dormant  reserve  energy  have  welled  up  from  the  depths  of  1[* 
his  being.  He  has  become  a  different  man.  His  own 
brothers  are  surprised  at  the  radical  transformation  of 
his  character. 

VIII.  Mr.  J.  L.  Irish.  Protestant.  Age  57.  Fam- 
ily   history    is     good,    except    for    the    fact    that    his 


i 


1^8  PSYCHOTHERAPEUTICS 

brother  is  also  addicted  to  drink  and  was  under  my  care 
for  a  few  weeks,  with  the  result  that  he  left  off  drink  for 
two  years.  Patient  is  a  printer  by  trade  and  has  been 
drinking  for  over  thirty  years.  While  he  is  usually  kind 
natured,  when  under  the  influence  of  drink  he  is  violent, 
abusive,  offensive  to  his  wife  and  children,  who  are  afraid 
of  him.  From  his  sister  and  wife  I  have  the  information 
that  the  patient  goes  off  periodically  on  a  long  spree  and 
spends  all  his  money,  neglecting  his  wife  and  children; 
when  he  comes  home  he  abuses  everybody  in  the  house. 
"  It  is  not  a  home,  it  is  a  hell,"  as  his  sister  puts  it.  In 
his  better  moments  the  patient  himself  admits  he  is  a 
brute,  that  drink  has  the  best  of  him.  He  must  keep 
away  from  drink  completely,  because  the  mere  taste  of 
it  sets  him  going.  An  examination  reveals  the  presence 
of  arteriosclerosis. 

I  attempted  to  put  the  patient  into  the  hypnotic  state, 
for  I  found  the  hypnoidal  state  would  meet  with  less  re- 
sistance and  suspicion  on  the  side  of  the  patient.  Hyp- 
noidization  then  was  the  order  of  the  day.  The  patient 
began  to  improve,  was  less  nervous,  slept  better,  and 
what  was  more  important,  stopped  drinking,  lost  all 
craving  for  liquor.  After  three  weeks  of  treatment  by 
means  of  hypnoidization  the  patient  was  discharged.  He 
did  not  drink  for  a  whole  year,  but  coming  in  contact 
with  other  workmen  in  the  union  he  was  invited  to  drink, 
could  not  refuse,  and  once  more  was  started  on  his  old 
career.  He  came  back  to  me,  and  this  time  I  treated 
him  daily  for  a  month.  Throughout  the  treatment  the 
hypnoidal  state  was  used.  The  patient  has  given  up  his 
drink  habit,  has  no  craving  for  liquor,  works  regularly 
at  his  job  and  no  longer  associates  with  companions  who 
are  given  to  drink.  His  sister  and  wife  keep  me  regu- 
larly informed  about  his  condition,  and  the  report  for 
the  last  two  years  has  been  "  John  is  very  good,  he  is  a 


f 


VALUE  OF  THE  HYPNOIDAL  STATE      129 

gentleman,  treats  the  children  well."     He  has  become  a 
model  father  and  a  good  husband. 

IX.  Mr.  C.  T.  Age  32.  American.  Father  was 
an  inveterate  drunkard  and  was  drowned  while  in  a  state 
of  intoxication.  A  maternal  as  well  as  a  paternal  uncle 
were  confirmed  drunkards.  There  was  also  drunkenness 
in  the  collateral  branches  of  the  family.  The  patient 
learned  to  drink  when  very  young.  His  mother,  who 
volunteered  the  information,  told  me  that  she  suspected 
that  her  son  began  to  drink  wine  at  the  age  of  seven. 
Since  that  time  the  drink-obsession  grew  on  him  and  he 
became  a  confirmed  drunkard  at  the  age  of  twenty.  The 
patient's  physical  condition  is  good.  The  emotional 
state  is  one  of  passive  indifference,  the  intellectual  activi- 
ties are  rather  in  abeyance,  the  general  disposition  is 
inoffensive  and  even  mild.  It  seems  that  the  alcohol  has 
soaked  out  of  him  all  his  strength.  He  has  no  ambition 
and  is  not  fit  to  do  anything,  as  he  is  constantly  under 
the  influence  of  liquor.  His  will  power  is  weak,  he  has 
no  sense  of  personal  responsibility,  and  nothing  of  any 
importance  can  be  intrusted  to  him.  Socially  he  is  ostra- 
cized by  his  relatives,  but  he  seems  to  mind  it  little. 

Considering  the  family  and  personal  history  of  the 
case  I  was  not  enthusiastic  over  the  outcome  of  the  treat- 
ment. The  family,  however,  insisted  on  treatment  and 
the  mother  was  anxious  to  have  me  undertake  the  case 
as  he  was  her  only  son.  The  treatment  lasted  for  about 
a  year  and  was  carried  out  by  means  of  the  hypnoidal 
state.  To  my  great  surprise  and  contrary  to  my  ex- 
pectations the  patient  has  given  up  his  drink.  He 
changed  so  much  that  even  his  mother  wondered  at  the 
transformation.  From  being  apathetic  he  became  am- 
bitious, from  being  dependent  he  became  self  reliant. 
He  manifested  a  self  control  which  none  of  his  intimate 


180  PSYCHOTHERAPEUTICS 

friends  ever  suspected  in  him.  He  became  methodical, 
systematic,  conscientious  in  his  work,  and  displayed  an 
unusual  ability  in  management.  From  being  weak,  ir- 
regular, and  unreliable,  his  character  became  energetic, 
firm,  and  trustworthy.  His  abilities  were  soon  noticed, 
appreciated,  and  he  has  since  become  a  manager  of  a 
large  concern.  Nowhere  have  I  observed  such  limita- 
tions, such  moral  infirmity,  such  lack  of  capacity,  change 
so  radically  to  strength  of  will  combined  with  a  sense  of 
personal  responsibility  and  vigor  of  intellectual  activity. 
Since  then  I  began  strongly  to  doubt  the  so-called  fatal, 
hereditary  dipsomania  of  psychiatric  text-books.  I  must 
say  that  I  now  completely  disbelieve  that  medico-calvin- 
istic  doctrine  of  "  total  inability  and  damnation,"  in 
regard  to  dipsomania.  There  may  be  hereditary  tenden- 
cies to  nervous  instability,  tendencies  to  excitement  with 
consequent  craving  for  stimuli  inducing  exaltation,  but 
certainly  there  is  no  hereditary  alcoholism.  What  sort 
of  stimuli  a  person  is  sensitive  to  depends  on  training 
and  environment.  It  may  be  art,  science,  politics,  reli- 
gion, or  drink.  There  is  no  more  hereditary  dipsomania 
than  there  is  congenital  gambling.  From  a  mere  anam- 
nesis no  snap  prognosis  should  be  made  without  giving 
the  case  a  good  trial  and  proper  treatment;  no  alcoholic 
patient  should  be  declared  as  hopeless. 

With  the  advance  of  my  psychopathological  studies 
and  psychotherapeutic  work  I  begin  to  have  more  confi- 
dence in  the  principle  of  dormant  reserve  energy  and 
have  more  trust  in  the  therapeutic  value  of  the  hypnoidal 
state. 


CHAPTER  SEVEN 

Obsessions   and   Associated    Conditions   in    So-called 
psychasthenia 

BY   JOHN  E.    DONLEY,    M.D. 

Physician  for  Nervous  Diseases^  St.  Joseph's  Hospital, 
Providencey  R.  L 

BY  the  term  obsession  I  shall  understand  any  recur- 
ring, extra-voluntary  idea,  feeling,  or  emotion 
which  presents  itself  automatically  in  conscious- 
ness, either  alone  or  in  combination;  and  the  clinical 
syndrome  characterized  essentially  by  such  obsession 
and  associated  states,  I  shall,  following  many  others,  call 
psychasthenia.  As  psychotherapeutists  we  are  inter- 
ested in  obsessions,  not  only  as  to  their  content^  that  is 
to  say,  the  particular  form  and  character  they  assume, 
but  also  and  equally,  if  not  indeed  chiefly,  as  to  their 
mechanism, —  the  manner  in  which  they  arise,  the  factors 
by  which  they  are  perpetuated,  and  the  methods  whereby 
they  may  be  either  alleviated  or  cured. 

Approaching  the  subject,  then,  from  this  angle,  we 
may  set  out  with  the  observation  that  every  obsession 
has  its  history  just  as  truly  as  has  a  paintmg,  a  poem, 
or  a  symphony.  Obsessions  are  not,  therefore,  as  is  so 
often  apparently  believed,  discontinuous  and  uncaused 
mental  experiences,  arising  nowhere  and  disappearing  no 
whither ;  they  are  just  as  much  products  as  are  any  other 
of  the  contents  of  consciousness ;  and  only  in  this  are 
they  sui  generis,  that  they  are  products  of  a  very  special 
and  peculiar  kind,  whose  genesis  it  may  or  may  not  be 
within  our  power  to  discover.  To  seek  out  the  psycho- 
genetic  mechanism  of  obsessions  is  accordingly  the  first 

131 


132  PSYCHOTHERAPEUTICS 

step  toward  a  rational  psychotherapy;  for  only  if,  and 
in  so  far  as,  a  careful  inquiry  of  this  sort  has  been  pre- 
liminary to  any  attempt  at  therapeusis,  can  the  latter 
hope  to  be,  in  some  manner  and  degree,  successful. 

The  pursuit  of  this  genetic  method  leads  straight  into 
the  complexities  and  difficulties,  sometimes,  indeed,  into 
the  frustrations  of  normal  and  abnormal  psychology. 
Yet,  however  difficult  this  domain  may  appear  to  be,  to 
enter  it  is  an  absolute  prerequisite  to  the  progressive 
treatment  of  psychasthenia. 

The  most  striking  attribute  of  obsessive  mental  states 
is  their  more  or  less  constantly  recurring  automatism. 
They  do  not  appear  as  normal  and  harmonious  elements 
/Within  the  conscious  stream;  on  the  contrary  they  are 
^  intruders  whose  constant  entrance  and  exit  disrupt  the 
customary  processes  of  mental  life.  In  the  language 
of  abnormal  psychology,  they  are  said  to  arise  as  men- 
tal states  or  complexes  which  have  been  dissociated  or 
split  oiF  from  the  main  stream  of  the  self-conscious  per- 
sonality. Whether  an  obsession  appears  in  conscious- 
ness as  a  complex  whose  nucleus  is  an  idea,  a  feeling,  or 
an  emotion,  it  is  to  be  looked  upon  as  having  its  origin 
in  the  same  psychological  mechanism,  namely,  dissocia- 
tion. The  psychological  details  of  this  dissociation  may 
vary  within  comparatively  wide  limits  in  particular  ob- 
sessions, but  the  general  underlying  principle  would  ap- 
pear to  be  the  same  in  all. 

In  the  evolution  of  an  obsession,  dissociation  is  but  one 
aspect  of  the  process;  for  association  comes  to  play  an 
equally  important  role  in  the  drama.  Given  a  disso- 
ciated mental  element,  whether  idea,  feeling,  or  emotion, 
this  mental  element  will  not  for  long  remain  isolated  and 
unattached,  but  in  accordance  with  the  laws  of  associa- 
tion will  connect  itself  with  some  other  conscious  content 
to  form  a  definite  complex,  upon  the  character  of  which 


CONDITIONS  IN  PSYCHASTHENIA        133 

will  depend  the  type  of  obsession  which  appears  in  con- 
sciousness ;  for  obsession  is  just  another  name  for  a  par- 
ticular, actively  functionating  complex. 

Now  this  obsessive  complex  may  be  of  multifarious 
composition;  it  may  be  composed  chiefly  of  ideational 
feeling,  or  emotional  constituents;  it  may  be  thick  or 
thin,  wide  or  narrow;  it  may  contain  many  elements  or 
few;  as  time  goes  on  it  may  function  in  its  original  in- 
tegrity or  may  become  split,  thus  giving  rise  to  curious 
and  perplexing  clinical  manifestations;  finally,  the  com- 
plex may  be  wholly  or  only  partially  conscious  or  sub- 
conscious; or  to  state  it  another  way,  the  obsessed 
individual  may  be  aware  of  much  or  of  little  concerning 
that  which  is  really  operative  in  the  production  of  his 
abnormal  mental  condition. 

We  said  a  moment  ago  that  association  plays  an 
equally  important  part  with  dissociation  in  the  mechan- 
ism of  obsessions.  Obviously  it  is  impossible  here  even 
to  name  the  numberless  associations  that  may  occur  be- 
tween the  conscious,  subconscious,  and  co-conscious  lev- 
els of  mind,  and  the  various  obsessive  complexes  which 
may  thus  arise.  One  may  point  out,  however,  the  impor- 
tant fact  that  these  associations  may  be  found  to  have 
taken  place  not  only  between  ideas  as  such,  but  also  be- 
tween any  and  all  of  the  other  elements  of  conscious- 
ness, as  well  as  between  these  latter  and  purely  physio- 
logical processes,  such  as  those  mediated  by  the  voluntary 
and  involuntary  musculature  and  by  glands.  Thus  it 
may  be  seen  that  the  variety  of  obsessions  is  coterminous 
with  the  possibilities  of  abnormal  association  and  disso- 
ciation ;  hence  also  the  impossibility  of  placing  a  limit  to 
the  patterns  according  to  which  obsessions  may  be 
formed. 

When  once  an  obsessive  complex  has  been  definitely 
established,   it  may  be   roused   to   future   activity  in   a 


134  PSYCHOTHERAPEUTICS 

variety  of  ways.  What  I  desire  especially  to*  call  at- 
tention to  here  is  the  law  of  the  substitution  of  stimulus, 
which  may  oftentimes  explain  the  active  functioning  of 
an  otherwise  most  puzzling  obsession.  Suppose  the  case 
where  a  person  has  had  a  painful  and  emotionally  upset- 
ting experience  with  a  cat.  Out  of  this  experience  may 
arise  an  obsessive  complex,  namely,  fear  of  cats.  In 
order  to  arouse  this  complex  to  activity,  it  is  not  neces- 
sary in  the  future  to  experience  the  actual  presence  of 
a  cat.  All  that  is  required  is  some  stimulus,  e.g.,  the 
mere  word  cat,  that  has  a  symbolic  relationship  with  the 
original  experience.  Or  take  the  case  of  a  patient  of 
mine  who  overheard  the  doctors  at  a  consultation  re- 
mark that  a  certain  pathological  condition  in  her  breast 
might  be  a  carcinoma.  As  a  matter  of  fact  it  turned 
out  to  be  nothing  of  the  sort,  yet  the  obsessive  fear  of 
carcinoma  of  the  breast  remained  with  her  for  many 
months.  In  order  to  rouse  her  obsession  it  was  neces- 
sary merely  to  present  to  her  something  having  a  direct 
or  indirect  symbolic  relationship  with  the  breast.  On 
one  occasion  she  was  calling  upon  a  friend  who  had  re- 
cently given  birth  to  a  daughter.  Out  of  the  clear  sky 
of  conversation  came  something  about  the  nursing  of 
the  child,  when  straightway  an  attack  of  obsession  oc- 
curred which  compelled  her  to  terminate  the  visit.  If 
we  bear  this  fact  of  substitution  of  stimulus  well  in  mind 
we  may  perhaps  be  able  to  explain  an  otherwise  perplex- 
ing assault  of  obsessions. 

Enough  has  now  been  said  perhaps  to  give  a  reason- 
ably clear  idea  of  the  psycho-genesis  of  obsessions, — 
their  origin  usually  in  some  previous  experience  of  the 
individual,  which  experience  is  either  not  remembered  at 
all,  or  if  so,  is  not  recognized  as  being  the  point  of  de- 
parture for  the  obsession;  their  formation  through  dis- 
sociation of  certain  mental  elements  ^nd  the  subsequent 


i 


CONDITIONS  IN  PSYCHASTHENIA        135 

association  of  these  elements  with  other  contents  of  con- 
sciousness to  form  an  obsessive  complex ;  and  finally  the 
automatic  and  recurrent  functioning  of  the  complexes 
thus  formed  within  the  field  of  the  conscious  personality. 

If  now  we  approach  the  treatment  of  these  psychas- 
thenic obsessions  we  have  at  our  disposal  a  variety  of 
methods  ranging  from  simple  explanation  and  persuasion 
on  one  iide  to  hypnoidization  and  hypnosis  upon  the 
other.  In  order  to  render  our  discussion  of  these  thera- 
peutic measures  as  concrete  as  possible,  I  shall  give  a 
brief  report  of  some  cases  actually  treated,  together  with 
an  account  of  what  was  done  in  each  individual  case. 

Case  I.  Mrs.  M.,  aged  thirty-five,  came  into  the  hos- 
pital upon  the  advice  of  her  physician,  complaining  of  a 
peculiar  constantly  repeated  and  involuntary  hacking, 
which  sounded  as  though  she  were  trying  to  clear  her 
throat.  Her  movements  involved  the  muscles  of  the 
larynx,  those  of  the  neck  and  thorax,  together  with  the 
diaphragm;  in  a  word  they  had  the  characteristics  of  a 
respiratory  tic.  Drugs,  local  applications  to  the  throat, 
and  electricity  had  been  tried  at  intervals  during  more 
than  four  years  without  avail.  Asked  regarding  the 
origin  of  her  nervous  ti^ouble,  the  patient  could  give  no 
information  except  the  fact  that  she  could  not  volun- 
tarily control  the  hacking.  She  was  then  placed  in  the 
hypnoidal  state  as  described  by  Dr.  Sidis,  when  the  fol- 
lowing history  was  obtained:  Five  years  ago  while  em- 
ployed as  an  operative  in  a  mill  she  suffered  from  a  sore 
throat  which  lasted  for  three  days,  at  the  end  of  which 
time  she  consulted  a  physician,  who  told  her  that  she  had 
tonsilitis  and  informed  her  that  it  would  be  necessary  to 
hum  out  her  tonsils.  She  was  much  frightened  by  this 
information  and  for  several  days  thereafter  felt  herself 
quite  disturbed.  Her  tonsillar  symptoms  soon  disap- 
peared and  she  returned  to  work.     Three  weeks  later, 


i 


136  PSYCHOTHERAPEUTICS  | 

however,  she  was  attacked  for  the  second  time  and  again 
consulted  another  physician  who  told  her  that  her  tonsils 
were  diseased  and  advised  her  to  have  them  cut  out.  The 
fear  of  cutting  added  to  her  previous  fear,  now  revived, 
of  burning  her  tonsils,  threw  her  into  such  a  nervous  state 
that  she  was  able  to  think  of  nothing  else.  At  this  time 
she  noticed  a  disagreeable,  stinging,  tickling  feeling  in 
her  throat,  which  she  tried  to  remove  by  hacking,  but 
without  success.  As  the  tickling  remained,  her  hacking 
became  more  and  more  frequent  and  at  the  time  she  came 
under  observation  had  taken  on  the  character  of  a  tic; 
for  she  said  she  felt  an  uncontrollable  impulse  to  hack 
although  she  confessed  there  was  little  if  any  abnormal 
feeling  in  her  throat.  Here,  then,  was  an  obsessive  com- 
plex discharging  itself  through  motor  pathways  as  a  tic 
and  having  its  origin  in  the  experiences  we  have  described. 
At  the  time  of  my  examination  she  admitted  that  the  fear 
of  a  possible  future  cutting  or  burning  of  her  tonsils 
still  possessed  her.  While  in  the  hypnoidal  state  she  was 
encouraged  and  helped  to  recall  the  complete  experience 
in  as  great  detail  as  possible.  She  was  then  told  with 
much  emphasis  that  her  tonsils  were  perfectly  healthy, 
that  no  cutting  or  burning  ever  was  or  ever  would  be  re- 
quired; that  the  tickling  sensation  in  her  throat  arose 
from  the  constant  fixation  of  attention  upon  this  part; 
that  she  would  feel  no  more  desire  to  hack  because  her 
supposed  reason  for  hacking  had  ceased  to  exist,  and 
finally,  that  when  she  should  open  her  eyes  she  would  feel 
better  than  she  had  in  a  great  many  years.  Much  em- 
phasis was  placed  upon  this  feeling  of  health  because  it 
was  desired  to  leave  her  on  the  crest  of  a  pleasurable 
emotion,  which  of  itself  has  a  very  great  suggestive  value. ^ 
What  had  been  predicted  in  her  regard  actually  occurred. 
When  she  sat  up,  her  tic  had  disappeared,  and  she  ex- 
pressed herself  as  feeling  quite  grateful  and  happy.    The 


CONDITIONS  IN  PSYCHASTHENIA        137 

seance  of  hypnoidization  lasted  an  hour,  and  except  for 
two  slight  recurrences  easily  removed  by  waking  sugges- 
tion, this  patient  has  had  no  further  difficulty. 

Case  II.  A  young  married  woman  came  under  obser- 
vation complaining  of  a  very  distressing  type  of  obses- 
sion,—  namely,  the  fear  of  losing  control  of  her  bladder. 
For  nine  years,  with  an  interval  of  some  six  months,  dur- 
ing which  she  was  comparatively  free,  this  imperative  fear 
had  dominated  her  mind,  so  that  her  life  had  been  ordered 
with  regard  to  the  demands  of  her  obsession.  Not  only 
did  she  have  the  mental  fear,  but  also  a  distressing  sensa- 
tion in  the  bladder  whenever  her  obsession  was  active.  It 
is  scarcely  possible  to  describe  the  suffering  which  she 
had  endured.  She  could  not  engage  in  the  social  func- 
tions which  she  enjoyed  for  fear  of  a  humiliating  acci- 
dent. The  theater  was  closed  to  her;  she  could  not  ride 
fdT  any  distance  upon  cars,  nor  accept  invitations  to  visit 
j^ny  one  save  friends  in  whose  houses  she  felt  at  ease.  In 
;  her  own  home  she  experienced  rather  a  different  feeling, 
—  not  the  fear  of  incontinence,  which  did  not  often  occur, 
but  the  depressing  idea  that  her  life  was  to  be  circum- 
scribed by  a  malady  over  which  she  had  no  control.  On 
the  theory  that  her  trouble  was  due  to  cystitis,  her  blad- 
der had  been  washed  out  with  various  solutions,  among 
them  boric  acid  and  nitrate  of  silver,  and  she  had  swal- 
lowed a  host  of  drugs  like  citrate  of  potassium,  buchu, 
and  oil  of  sandalwood.  From  a  careful  consideration  of 
her  history  it  seemed  reasonable  to  suppose  that  her  blad- 
der sensations  were  secondary  to  her  obsession,  rather 
than  that  her  obsession  was  consequent  upon  a  real  cys- 
titis. An  examination  of  her  urine,  which  contained  noth- 
ing abnormal,  confirmed  this  view.  Upon  the  principle 
that  every  obsession  has  a  history,  if  only  we  can  dis- 
cover it,  an  attempt  was  made  to  determine  the  origin  of 
this  one.     No  special  devices  were  employed  other  than 


138  PSYCHOTHERAPEUTICS 

a  precise  reconstruction  of  the  clinical  history.  It  then 
appeared  that  some  nine  years  ago,  a  few  days  after  the 
birth  of  her  first  child,  she  was  troubled  while  in  bed  with 
a  slight  degree  of  cystitis  and  as  a  fact  did  lose  control 
of  her  bladder.  This  made  her,  as  she  says,  rather 
ashamed  of  herself,  and  struck  her  as  being  an  unfortu- 
nate occurrence.  Some  few  weeks  later,  while  out  walk- 
ing, she  suddenly  felt  a  curious  burning  sensation  in  her 
bladder.  Immediately  she  was  seized  with  the  fear  that 
there  was  to  be  another  loss  of  control ;  this,  however,  did 
not  happen.  Nevertheless  the  fear  continued,  and  has 
persisted  to  within  a  very  recent  period.  Here,  then,  was 
an  obsession  of  disagreeable  type,  which  had  arisen  upon 
the  basis  of  a  previous  experience.  The  memory  of  an 
actual  loss  of  bladder  control  plus  a  certain  sensation 
referred  to  the  bladder  had  become  associated  in  a  com- 
plex which  functioned  as  an  obsessive  fear  of  incon- 
tinence. While  the  patient  could  recall  perfectly  her  ex- 
periences as  given  above,  she  had  no  idea  that  they  had 
anything  to  do  with  her  present  fear  until  this  was 
pointed  out  to  her,  whereupon  she  acquiesced  readily  in 
this  explanation.  Before  her  treatment  had  progressed 
further  than  the  second  consultation,  an  opportunity 
presented  itself  of  testing  the  truth  of  our  hypothesis, 
namely,  that  her  bladder  symptoms  were  the  tail  to  a 
mental  kite.  On  this  special  occasion  she  was  compelled 
to  wait  some  little  time,  and  when  I  began  to  talk  to  hen 
it  was  very  evident  that  her  obsession  was  in  full  swing. 
An  attempt  was  made  then  and  there  to  disrupt  her  ob- 
sessive complex  by  forcibly  replacing  for  the  association 
represented  by  "  bladder  loss  of  control,"  another  asso- 
ciation, "  bladder  full  control."  This  was  accomplished 
by  stating  and  restating  very  positively  and  in  detail 
that  she  could  certainly  control  her  bladder,  as  the  event 
would  surely  prove.     For  about  twenty  minutes  her  emo- 


I 


CONDITIONS  IN  PSYCHASTHENIA        139 

tional  agitation  was  intense,  but  finally  subsided  with  the 
result  that  although  she  was  anything  but  calm,  her  faith 
in  her  obsession  had  been  somewhat  diminished.  By  dint 
of  subsequent  and  repeated  persuasion  her  fear  was 
finally  removed,  so  that  ultimately  at  the  end  of  eight 
months  she  entered  upon  her  social  pleasures  and  duties 
with  normal  satisfaction.  Untiring  persuasion  in  the 
face  of  obstacles  had  succeeded  in  disrupting  an  obsessive 
complex  which  for  nine  years  had  proved  rebellious  to  all 
other  medical  treatment. 

Case  III.  A  man,  aged  32,  presented  a  very  interest- 
ing obsession,  which  was  this:  he  could  not  get  upon  a 
street  car  whose  number  was  odd.  Cars  with  even  num- 
bers gave  him  no  trouble,  but  if  an  odd  numbered  car 
came  along  he  was  compelled  to  let  it  pass  no  matter 
what  his  hurry  might  be.  He  could  recall  nothing  which 
would  shed  light  upon  this  curious  obsession,  but  when  v'^ 
placed  in  hypnosis  he  gave  the  following  story:  When 
about  eighteen  years  old  he  was  one  day  walking  upon 
the  street  when  he  witnessed  a  street  car  strike  and  in- 
jure a  child  who  unexpectedly  ran  out  from  behind  a 
wagon.     The   sight    of  this    accident   gave   him   a   very  , 

marked  emotional  shock,  which  upset  him  for  several  days  Lyjr 
thereafter.  Standing  near  the  scene  of  the  accident  he ' 
noticed  that  the  car  bore  the  number  213,  and  thought  to 
himself,  "  Well,  there  is  always  ill-luck  in  13."  Ever 
since  the  time  of  this  experience  he  has  had  his  strange 
aversion  to  riding  upon  cars  bearing  odd  numbers,  al- 
though his  waking  self  could  give  no  account  of  or  even 
conjecture  regarding  the  derivation  of  his  obsession. 
During  hypnosis  it  was  suggested  to  him  that  the  child 
whose  accident  he  witnessed  was  not  really  injured  and 
had  recovered  completely.  Furthermore,  he  was  told 
that  odd  numbers  were  quite  the  same  as  even  numbers; 
that  they  would  no  longer  cause  him  any  trouble,  and  in 


140  PSYCHOTHERAPEUTICS 

fact  would  give  him  no  concern  whatever ;  and  finally  that 
like  all  other  normal  persons  he  would  pay  no  attention 
to  the  number  of  the  car  he  desired  to  ride  upon.  These 
hypnotic  treatments  were  continued  daily  for  eight  days 
and  resulted  in  the  complete  removal  of  the  obsession, 
which,  so  far  as  I  know,  has  not  returned. 

Case  IV.  A  young  woman,  by  occupation  a  stenog- 
rapher, complained  of  an  obsession  which  took  the  form 
of  a  more  or  less  troublesome  fear  of  insanity.  She  was 
conscious  that  her  intellectual  activity  was  practically 
normal,  because  she  was  engaged  daily  in  an  exacting 
profession,  which  she  carried  out  with  complete  success. 
This  fear,  however,  of  insanity,  while  not  painfully  im- 
perative, was  nevertheless  present  on  occasion  as  a  dis- 
turbing under-current  in  her  mind.  She  did  not  appre- 
ciate the  origin  of  her  fear  until  it  was  disclosed  to  her 
as  follows:  About  two  years  previously,  while  sitting  in 
her  room  one  night,  she  was  locked  in  by  another  woman 
in  the  house  who  had  become  unbalanced  in  mind.  Be- 
ing unable  to  release  herself  from  her  confinement,  on 
account  of  the  door  having  been  locked  from  the  outside, 
she  spent  something  over  an  hour  in  dread  of  what  might 
happen  to  her  should  the  woman  return  and  attempt  to 
enter  the  room.  As  a  matter  of  fact,  nothing  of  this 
sort  occurred,  for  she  was  released  from  her  confinement 
by  another  dweller  in  the  same  house.  Naturally,  she 
was  very  much  upset,  and  from  that  time  until  she  came 
under  observation  suffered  from  this  disquieting  fear  of 
insanity.  It  was  not  difficult  to  trace  the  origin  of  the 
obsessive  complex.  Psychologically,  it  was  merely  the 
persistence  in  her  mind  of  the  memory  of  her  former 
experience,  bereft  of  its  characteristics  as  a  memory. 
There  had  thus  arisen  an  obsessive  complex  which  func- 
tioned automatically  and  appeared  in  consciousness  as 
a  present  fear  of  mental  disease.     By  means  of  j)ersuasion 


I 


CONDITIONS  IN  PSYCHASTHENIA        141 

and  ^planation,  the  whole  matter  was  explained  to  her, 
and  in  the  couTS^  of  about  four  weeks  she  found  her  fear 
gradually  fading  until  eventually  she  had  substituted  a 
complete  understanding  of  the  situation  for  her  obses- 
sion, and  this  brought  about  its  ultimate  removal. 

In  the  cases  just  described,  one  may  observe  the  suc- 
cessful results  that  sometimes  follow  the  use  of  hypnosis, 
hypnoidization,  and  persuasion,  in  the  treatment  of  psy- 
chasthenic obsessions.  I  would  not,  however,  wish  to  con- 
vey the  impression  that  every  case  which  clinically  mani- 
fests itself  by  psychasthenic  symptoms  is  treated  with 
equally  great  success.  Some  of  them  are  extremely  ob- 
scure as  to  their  genesis,  and  equally  difficult  in  the  way 
of  successful  treatment.  In  conclusion,  I  wish  to  de- 
scribe such  a  case,  which  was  characterized  by  obsessions, 
feelings  of  unreality,  incompleteness,  and  strangeness, 
and  to  some  extent  by  depersonalization. 

Case  V.  Mr.  X.,  by  occupation  a  postman,  complained 
that  from  the  time  he  was  about  seventeen  years  of  age 
he  had  been  afflicted  with  feelings  of  incompleteness,  by 
obsessions  of  fear  of  insanity,  and  by  the  lack  of  emo- 
tional reaction  to  his  environment,  whether  pleasurable 
or  painful.  Throughout  his  life,  as  long  as  he  could  re- 
member, he  had  always  been  reticent,  and  as  a  boy  found 
it  difficult  to  associate  with  his  playmates  because  of  shy- 
ness. On  one  occasion,  when  at  school,  he  attempted  to 
give  a  recitation,  but  failed  through  an  acute  attack  of 
stage  fright.  He  got  along  tolerably  well  until  he  was 
seventeen,  when  he  suffered  an  attack  of  typhoid  fever, 
at  which  time  the  more  troublesome  symptoms  of  which 
he  complains  began.  He  says  that  he  seems  to  lack  the 
ability  to  feel  pleasure  or  pain  in  what  he  does.  At  the 
theater,  for  example,  he  experiences  no  emotion,  but  sits 
there,  as  he  says,  "  equally  indifferent  to  whatever  may 
be  going  on."     He  sees  the  play  and  hears  the  actors,  but 


142  PSYCHOTHERAPEUTICS 

cannot  get  in  tune  with  them.  In  his  daily  w.ork  of  de- 
livering letters  he  finds  no  pleasure,  except  that  it  serves 
him  as  a  means  of  occupation  and  a  source  of  livelihood. 
Constantly  throughout  the  day,  more  particularly  when 
he  is  unoccupied,  the  thought  flashes  into  his  mind  that 
he  is  going  to  become  insane,  or  that  his  malady  will  ter- 
minate in  complete  despair.  He  used  to  enjoy  the  read- 
ing of  poetry,  but  complains  that  now  poems  are  to  him 
merely  so  many  words,  and  that  while  he  understands 
what  the  poet  is  trying  to  convey,  he  derives  no  answer- 
ing emotion  from  his  reading.  He  states  his  feelings 
thus :  "  I  seem  to  myself  to  be  another  person.  It  appears 
to  me  that  there  is  a  split  between  my  emotional  and  my 
intellectual  nature.  I  cannot  get  in  tune  with  things, 
and  the  greatest  good  fortune  or  the  greatest  misfortune 
in  the  world  would  leave  me,  I  believe,  equally  unaffected." 
Throughout  several  months  the  attempt  has  been  made 
by  psycho-analysis  to  uncover  some  source  for  the  psychas- 
thenic symptoms  presented,  but  without  success.  His 
seems  to  be  one  of  those  cases  wherein  the  psychasthenic 
feelings  of  incompleteness,  insufficiency,  and  strangeness, 
together  with  obsessions,  are  so  interwoven  with  the  tex- 
ture of  the  mind  as  to  render  their  complete  removal  prac- 
tically impossible.  No  matter  what  he  attempts  to  do, 
there  is  a  fundamental  perversion  of  feeling  and  emotion, 
and  so  long  as  this  is  present,  his  obsessions  of  anxiety^ 
and  despair  arise  and  continue.  By  persuasion  and  fre^ 
quent  practice  he  has  been  enabled  so  to  switch  his  ob- 
sessions into  a  corner  of  his  mind  as  to  enable  him  to  pur- 
sue his  daily  work  with  a  certain  external  and  mechanical 
success.  This,  however,  requires  a  constant  effort  on  his 
part,  because  there  is  always  a  tendency  for  his  psychas- 
thenic symptoms  to  obtrude  themselves.  Hypnoidiza- 
tion  and  hypnosis  have  been  of  some  value  in  the  sense 
that   after   a   treatment  he   experiences   a   certain   relief 


CONDITIONS  IN  PSYCHASTHENIA        143 

for  a  time,  but  this  never  lasts  more  than  two  or  three 
days,  at  the  most.  His  treatment  has  extended  over  the 
greater  part  of  a  year,  but  it  must  be  said  that  the  psy- 
chasthenic substrata  of  mind  continues  virtually  un- 
changed. 


I 


\ 


\i  CHAPTER  EIGHT 

PSYCHOPROPHYLAXIS  IN   CHILDHOOD 
BY  TOM  A.  WILLIAMS,  M.B.,  CM.    (eDIN.) 

Lecturer  on  Nervous  and  Mental  Diseases ^  Howard  Univ.,  and 
Neurologist  to  Freedmans  Hospital 

DEFINITION.  Just  as  psychotherapy  denotes 
not  treatment  of  the  mind,  but  treatment  by 
psychic  means  (1),  so  I  shall  use  the  word 
psychoprophylaxis,  not  to  signify  the  prevention  of 
psychic  disorders,  but  to  mean  the  preservation  of  health 
by  psychic  means. 

The  limited  amount  of  space  at  my  disposal  will,  however, 
restrict  the  consideration  of  the  subject  to  the  psychic 
means  to  be  employed  for  the  restriction  of  psychic  dis- 
orders, leaving  aside  the  fascinating  psychoprophylactic 
procedures,  which  are  one  of  the  main  elements  used  by 
the  physician  to  persuade  patients  whose  symptoms  have 
been  long  absent,  to  regulate  their  life  so  as,  for  instance, 
to  prevent  failure  of  cardiac  compensation  and  asystole, 
or  to  continue  a  mercurial  course;  or,  again,  in  order  to 
cure  an  incipient  tuberculosis,  to  persuade  them  to  con- 
tinue to  visit  him,  to  avoid  foul  air,  take  regular  meals, 
and  avoid  excesses  of  work  and  pleasure.  Still  more 
largely  is  psychoprophylaxis  employed  by  the  sanatarian, 
who  persuades  first  his  colleagues,  later  public  opinion, 
and  lastly  legislatures  and  municipalities  to  adopt  the 
means  for  the  prevention  of  the  disease.  For  instance, 
the  greatest  obstacle  to  the  employment  of  efficient  means 
to  combat  yellow  fever  lay  in  the  psychological  attitude 
of  the  people  of  the  South.  Their  horror  of  "  yellow 
jack"  was  so  great  that  they  could  not  even  discuss  the 
subject.     It  was  only  when  some  hope  was  inspired  that 

144 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     145 

the  dreaded  disease  might  be  prevented  that  the  phobia 
could  be  controlled  sufficiently  to  permit  of  action. 

In  short,  the  means  of  overcoming  public  and  personal 
apathy  and  mental  inertia  are  the  most  difficult  problems 
of  preventive  medicine.  Were  this  done,  the  tuberculosis 
dispensary  would  really  perform  the  functions  it  is  sup- 
posed to  perform,  and  which  I  am  assured  it  does  not  do 
from  a  lack  of  this  psychic  motive  power  of  persuasion. 
The  disgraceful  typhoid  situation  in  Pennsylvania  will 
terminate  only  when  the  people's  feelings  are  aroused  by 
conviction  to  the  pitch  of  real  will  that  the  abuse  shall 
cease. 

Only  those  ignorant  of  psychology,  and  especially  lay- 
men, and  more  particularly  ecclesiastics,  who  are  always 
dualists,  will  expect  too  much  from  psychoprophylaxis. 
The  physician  is  not  likely  to  forget  the  state  of  physical 
nerve  insufficiency  (10),  which  is  at  the  root  of  so  many 
psychic  perturbations,  which  are  often  mere  exaggera- 
tions of  the  tendencies  of  the  character,  normal  and  mor- 
bid ;  nor  will  the  physician  forget  the  role  of  intoxication 
in  inducing  mental  confusion,  melancholy,  acute  psychas- 
thenic symptoms,  twilight  states,  often  miscalled  hys- 
terical. The  physician  will  take  care  that  the  exhortation, 
advice,  and  instruction  he  brings  to  bear  are  not  ob- 
structed by  the  intellectual  handicap  of  exhausted  or  in- 
toxicated neurones  (11),  nor  by  the  affective  distress 
caused  by  insufficient  oxidation,  intestinal  irritation,  and 
so  on. 

In  other  words,  he  will  adopt  a  monistic  interpretation 
of  his  patient,  contrary  to  the  view  of  Dejerine  (12), 
who  has  said  that  to  be  a  good  psychotherapeutist  one 
must  not  be  a  determinist.  He  has  not  taken  into  con- 
sideration the  fact  that  the  therapeutist  himself,  in  be- 
coming part  of  the  patient's  environment,  determines  a 
new  sequence  of  ideas.     On  the  contrary,  as  monists  we 


1 46  PSYCHOTHERAPEUTICS 

shall  protect  our  patient  from  such  dualistic  vagaries  as 
Christian  Science,  for  with  the  monistic  attitude  we  are 
much  more  apt  to  constantly  relate  mind  and  brain  to 
one  another. 

But  one  must  be  careful  to  avoid  the  pitfall  into  which 
many  psychiatrists  at  one  time  fell,  but  which  we  now 
know  how  to  avoid,  thanks  to  the  efforts  of  the  French 
school  and  of  men  like  Adolph  Meyer  and  Morton  Prince 
in  America.  I  refer  to  the  premature  attempt  to  refer 
every  psychic  perturbation  to  a  vice  of  structure,  as,  for 
example,  is  done  by  Swift  (13)  when  he  relates  the  differ- 
ence of  mental  capacity  between  the  adult  and  a  child 
of  seven  to  corresponding  neural  changes.  As  a  matter 
of  fact,  such  difference  is  one  merely  of  orderliness  of 
mental  reactions,  as  is  shown  by  the  superiority  of  the 
child  in  acquiring  unrelated  facts,  as,  for  instance,  words 
and  the  use  of  language.  A  man  deprived  of  education 
would  show  no  greater  capacity  and  have  perhaps  less 
potentiality  than  a  child  of  seven.  Of  course,  ultimately, 
any  acquired  skill  must  depend  upon  neuronic  dispositions 
of  molecular  kind ;  but  we  are  not  even  in  a  position  to 
perceive  the  nature  of  these,  though  that  they  depend 
upon  the  functional  capacity  of  the  neurones  is  evident 
from  the  disappearance  of  skill  and  other  forms  of  mem- 
ory during  intoxication,  as  well  as  after  destruction  of 
nerve  matter. 

Thus,  as  of  all  prophylaxis,  an  essential  preliminary  is 
diagnosis,  by  which  only  an  intelligent  prophylaxis  can 
be  guided. 

The  essence  of  psychoprophylaxis,  as  of  psychotherapy 
and  education,  is  to  associate  useful  activities  with  agree-  / 
able  feeling-tones,  and  to  disassociate  from  useless  or  in-  / 
jurious   acts  the  agreeable  feeling-tones  that  may  have 
been  acquired.     For  instance,  the  kind  of  social  obsession  / 
which  eventuated  in  the  crusades  does  not  differ  psycho- 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     147 

logically  from  that  which  leads  to  empire  building;  but 
the  former  was  a  pernicious  activity,  while  the  latter 
may  have  its  uses.  A  fixed  idea  may  often  prove  an 
incentive  to  useful  work  in  individuals  as  well  as  in  so- 
cieties. 

Fundamentally  none  of  the  processes  we  employ  dif- 
fers from  those  used  by  Pawlow  (2)  in  "  conditioning  " 
the  reflexes  of  his  experimental  dogs,  when  he  caused  an 
expectant  wagging  of  the  tail  and  a  flow  of  saliva  and 
gastric  juice  upon  ringing  a  bell. 

Similarly,  when  the  petted  child  ceases  his  crying  upon 
seeing  his  father,  it  is  because  he  reflexly  has  associated  a 
greater  discomfort  with  the  persistency  of  his  tears  than 
with  their  cessation.  The  eff'ect,  fear,  aroused  by  as- 
sociation, banishes  that  of  fretfulness. 

Gradually  the  emotional  element  of  the  reflex  fades 
(3),  and  sight-of- father  connotes  cessation-of-weeping. 
This  leads  to  a  respect-reflex.  On  the  contrary,  the  in- 
tellectual content  of  the  phenomenon  may  be  submerged 
below  the  threshold  of  consciousness,  only  the  eff'ect  per- 
sisting; in  which  case  occur  painful  or  pleasurable  emo- 
tions, the  origin  of  which  is  not  manifest  in  the  subject. 
Recollect  that  functional  derangement  may  continue  just 
because  it  began. 

The  interest  sentiment  is  an  essential  of  all  psycho- 
therapy, as  of  eff^ective  pedagogy ;  as  when  a  young  child 
about  to  cry  is  quickly  diverted  to  a  passing  scene  or 
made  to  perform  an  act.  The  doing  so  quickly  substi- 
tutes the  new  interest  sentiment  for  the  disagreeable  for- 
mer one,  the  feelings  are  changed,  and  we  have  performed 
psychotherapy  by  distraction  and  substitution. 

This  simple  principle,  then,  of  finding  or  creating  the 
interest-eff^ect,  associating  it  with  the  desired  conduct, 
and  training  it  into  habit,  as  simply  illustrated  above, 
may  be  found  at  the  bottom  of  even  the  complicated  ratio- 


148  PSYCHOTHERAPEUTICS 

cinations  required  in  the  therapy  of  the  psychasthenic, 
and  is  also  the  outstanding  indication  in  all  paranoid 
psychoses. 

On  the  other  hand,  in  the  hysteric,  if  the  tour  de  force 
cannot  be  employed  or  fails,  the  method  of  repetition  is 
requisite.  Those  who  do  not  depend  upon  reason  must 
grow  into  feeling  by  accustomedness,  if  the  first  blow 
fails.  Who  does  not  know  of  communities  where  a  doc- 
tor's prestige  is  measured  by  the  years  he  has  spent  there, 
of  the  reverence  derived  from  seniority  .^^  The  mentality 
which  accedes  to  such  a  criterion  is,  of  course,  irrational, 
and  it  is  at  bottom  that  of  the  hysteric.  Hence,  the 
clinical  procedure  of  isolation  to  increase  the  speed  of  ac- 
customedness, and  of  reiteration  to  force  into  the  un- 
reasoning aflPectivity  a  realization  of  the  notions  to  which 
the  patient  is  refractory.  This  is  not  persuasion:  it  is 
the  method  of  pertinacity. 

Hypnosis,  hypnoidization,  etc.,  are  merely  means  of 
increasing  impressionability  to  suggestions.  In  principle 
there  is  no  difference  between  these  and  such  means  as 
were  empirically  used  in  ancient  times  through  cere- 
monies, religious  observances,  ritual,  etc.,  for  the  same 
purpose.  (Such  methods  can  perform  nothing  morC 
wonderful  than  Judge  Lindsay's  feat  of  persuading  the 
incorrigible  truant  boy  to  himself  purchase  a  ticket  and 
travel  many  hours  to  a  reform  school.) 

As  set  forth  elsewhere,  the  distinction  between  sugges- 
tion and  persuasion  is  one  of  awareness  by  the  percipient 
(4),  the  acceptee.  Hence,  to  be  unaware  of  why  one  ac^ 
cepts  an  opinion  that  so  and  so  is  the  most  skillful,  and 
to  do  so  on  length  of  acquaintance  is  to  do  so  by  sugges- 
tion;  and  an  idea  received  by  suggestion  is  a  hysterical 
one,  as  shown  by  Babinski  in  his  definition,  "  A  hysterical 
symptom  is  one  susceptible  of  induction  by  suggestion 
and  of  removal  by  suggestion  —  persuasion.     (5)" 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD    149 

In  all  of  these  procedures  the  preliminary  sentiment  of 
respect,  reverence,  awe,  is  engendered  among  the  people 
by  the  devices  of  expectation,  unfamiliarity,  and  sacred- 
ness  or  mystery.  This  sentiment  in  modern  democratic 
days  is  less  the  actuating  factor  than  that  of  the  pseudo- 
intellectual  shibboleth,  which  seems  to  be  a  strongly  de- 
termining ,  factor  in  the  popularity  of  modern  move- 
ments of  all  kinds.  The  social  tropisms  of  the  unthink- 
ing may  be  graded  in  three  categories  of  decreasing 
strength,  beginning  in  ritual  and  passing  via  shibboleth 
to  snobbery,  its  modern  attenuated  form.  In  all  these 
modes  of  conveying  influence,  distraction  is  obtained  by 
engaging  the  sight  by  the  rhythm  of  the  ceremony  and 
by  engaging  the  hearing  by  the  rhythm  of  music,  to 
which  are  often  added  the  dynamic  rhythms  of  move- 
ments directed  conformably  with  the  desires  of  the  priest 
or  other  operator. 

The  distraction  thereby  obtained,  almost  tantamount 
in  some  cases  to  a  dreamy  state,  favors  what  we  nowa- 
days variously  call  passivity,  psychological  automatism, 
mental  dissociation,   suggestibility. 

In  this  state,  plasticity  of  the  desires  is  much  facili- 
tated, the  operations  of  the  will  are  in  abeyance ;  for  the 
critical  judgment  of  the  intelligence  is  no  longer  in 
action.  The  subject  does  not  attain  to  the  phantas- 
magoria of  the  complete  dream  state;  for  susceptibility 
to  extraneous  stimuli  is  much  stronger  than  in  sleep,  or 
even  than  in  somnambulism.  The  state  resembles  that 
in  the  day-dream,  in  which,  however,  the  meditations  are 
less  systematically  determined. 

The  moral  control,  the  psychoprophylaxis,  secured  by 
these  means  has  in  the  past  been  incalculable ;  but  as  the 
sanction  of  these  procedures  has  been  crumbled  by  the 
trenchancy  of  modern  analysis,  and  we  now  live  in  a 
scientific  age,  it  is  necessary  to  employ  psychoprophy- 


150  PSYCHOTHERAPEUTICS 

lactic  means  which  accord  with  the  intellectual'  develop- 
ment of  civilized  man.  Thus  the  further  we  depart  from 
the  methods  of  mental  distraction,  mystical  appeal,  and 
pseudo-scientific  shibboleths  (6),  the  more  soundly  and 
permanently  shall  we  succeed  in  preventing  the  vagaries 
of  the  neurotic,  and  the  less  shall  we  be  a  party  to  the 
justification  of  the  occult  manner  in  which  many  of  the 
public,  and  even  some  doctors  conceive  such  psychological 
interpretations  as  hypnosis,  sub-consciousness,  divided 
personality,  subliminal  phenomena,  mental  dissociations, 
etc.  The  more  we  appeal  to  the  method  of  common 
sense,  plain  matter  of  fact  every  day  conduct  (which  is 
obviously  the  method  so  clearly  explained  and  outlined 
by  Dr.  Taylor)  (7),  the  less  chance  shall  we  give  for  the 
delusional  interpretations  of  clairvoyants,  medium  spir- 
itualists, and  others  whose  sentiment  of  psychic  imper- 
fection leads  them  to  seek  in  the  occult  the  satisfaction 
they  cannot  find  in  current  explanations  of  their  mental 
life. 

It  is  to  be  hoped  that  our  labors  along  with  other  sym- 
posia like  this  may  eventuate  in  a  working  doctrine  held 
in  common  by  the  whole  medical  profession,  which  will 
enable  us  to  forestall  and  prevent  the  development  of 
misinformation  concerning  psychic  states  which  have 
been  responsible  for  the  birth  and  evolution  of  such 
modern  movements  as  Christian  Science,  Emmanuelism, 
neo-yogiism,  and  other  harmful  misapplications  of  psy- 
chotherapeutics. 

A  concrete  illustration  of  what  psychoprophylaxis  can 
do  is  afforded  by  a  recent  communication  of  G.  Guidi 
(8),  who  has  shown  that  fifteen  per  cent  of  attacks  of 
migrain  are  preceded  even  for  days  by  psychic  symptoms 
either  of  excitable  or  depressant  type,  e.g.,  the  need  to 
move  about,  to  talk,  to  tell  funny  or  obscene  stories,  to 
look  out  for  ridiculous  situations,  to  laugh  at  them,  or 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     151 

by  a  desire  to  go  alone,  irritability,  sadness,  anxiety, 
even  tears.  I  have  myself  noticed  a  feeling  of  unusual 
mental  clarity,  of  power,  in  certain  cases.  (Every  one's 
disposition  is  modified  (9)  by  exercise,  oxygen,  food, 
etc. ;  we  all  have  defective  times.  Want  of  exercise  and 
elimination  leaves  toxins  which  cause  restlessness,  irrita- 
bility and  prevent  quiet  intellectual  work.)  Now  if  the 
migrainous  attack  can  be  prevented  as  a  result  of  diag- 
nosing this  modified  psychic  state,  it  is  evident  that  by 
prescribing  mental  and  physical,  including  digestive,  rest, 
we  shall  have  performed  psychoprophylaxis. 

We  must  recollect  that  during  the  period  while  the 
functions  of  the  neurones  are  perverted  by  physical  mal- 
adies, especially  the  intoxicative  ones  which  we  call  fevers, 
bad  habits  of  action  may  be  initiated  and  be  reinforced 
through  convalescence  and  become  characteristics  of  the 
individual.  As  a  matter  of  fact  more  careful  psychic 
discipline  is  needed  while  neurotic  activity  is  perverted 
(14)  than  when  it  is  healthy,  and  it  is  the  family  phy- 
sician's task  to  guide  the  psychic  management  of  his  pa- 
tients as  well  as  the  physical. 

The  principle  of  mental  prepossession  and  inertia 
shows  the  power  of  an  idea,  which  may  originate  as  the 
result  of  slight  physical  disorder.  Binet  (15)  has  illus- 
trated this  experimentally  by  showing  how  children  will 
go  on  increasing  the  length  of  a  line  when  drawing  from 
memory  a  series  of  lines  shown  them,  though  only  the 
first  few  of  them  were  actually  increased.  Another  ex- 
ample (16)  is  the  remarkable  experience  of  the  enumer- 
ators of  the  last  census  in  endeavoring  to  adapt  them- 
selves to  the  supposed  difficulties  of  a  new  dactylograph. 
Their  work  was  rendered  so  disappointing  by  the  "  press- 
ing "  under  difficulties  that  new  clerks  had  to  be  em- 
ployed: these  quickly  surpassed  their  more  experienced 
colleagues.     To  be  "  on  edge  "  is  not  the  best  state  for 


1 52  PSYCHOTHERAPEUTICS 

showing  high  skill:  as  every  golfer  knows,  it-  connotes 
divided  attention. 

The  state  of  keyed-up  prepossessedness  is  induced  by 
an  excessive  interference  (19)  with  the  activities  of  the 
child;  when  every  act  has  been  regulated  and  controlled, 
he  will  constantly  be  referring  for  approval  instead  of 
confining  himself  to  the  task  in  hand.  This  principle 
may  be  illustrated  by  the  boy  who  instead  of  looking  at  a 
ball  he  is  expected  to  catch  looks  at  the  thrower  for  the 
approval  or  blame  he  anticipates.  Over-conscientiousness 
is  quickly  developed  by  such  procedure;  but,  again,  psy- 
cho-diagnosis will  eliminate  the  danger,  for  it  would  be 
a  mistake,  for  fear  of  risking  over-conscientiousness,  to 
have  upset  the  entire  sense  of  fitness  of  a  boy  of  three 
who  came  to  his  father  to  be  thrashed,  declaring  he  had 
thrown  a  knife  at  the  cook,  an  act  which  had  been  spe- 
cifically forbidden. 

The  source  of  another  danger  proceeding  from  over- 
conscientiousness  is  that  of  shame  of  eating  (18),  as 
illustrated  by  the  same  boy,  when  conscious  of  wrong- 
doing, repeating  "  no  bananas  for  boy "  (a  dish  he 
loves).  But  it  is  very  easy  to  prevent  a  perverted  affect 
in  this  case,  while  at  the  same  time  furnishing  a  consist- 
ent and  coherent  system  of  conduct  and  morality. 

In  this  connection  one  must  avoid  formation  of  bad 
affective  habits  during  the  temporary  intoxication  of 
poor  oxydation  due  to  a  full  stomach  or  too  heavy  a  meal. 
In  this  state  a  child  while  playing  hard  may  be  car- 
ried away  by  excitement  till  he  loses  his  temper  and 
begins  to  cry,  just  because  "things  are  too  much  for 
him." 

Again,  constantly  interrupting  him  in  a  train  of 
thought  by  regulating  his  least  little  impulse  promotes 
suggestibility,  and  the  child  becomes  accustomed  not  to 
act  until  told.     In  not  availing  one's  self  of  a  moment  of 


I 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     153 

excitement  to  inculcate  a  difficult  act,  one  loses  a  chance 
of  cultivating  presence  of  mind,  even  during  emotional 
states.  This  may  even  be  done  during  pain  and  tears  by 
making  the  child  do  something  else  during  them,  thus 
gaining  self-control.  In  speaking  slightingly  of  what 
one  wishes  contemned,  be  sure  it  is  not  against  human 
nature.  To  forbid  healthy  acts  to  a  boy  is  detrimental 
to  him,  he  derives  a  false  notion  of  morals  when  he  knows 
that  innocent  acts  are  forbidden.  So  provide  ample  out- 
let for  spirit  of  adventure,  without  which  a  boy's  whole 
character  suifers.  It  either  is  exercised  illicitly,  or  is 
suppressed  and  forms  intellectual  dishonesty  and  emo- 
tional incompleteness,  so  fertile  a  source  of  psychas- 
thenia. 

But  in  early  childhood,  and  in  some  matters  even  in 
adolescence,  it  is  best  to  employ  authoritative  affirmation 
rather  than  suggestion.  A  child  cannot  see  the  reasons 
for  the  need  for  certain  prohibitions ;  and  it  is  a  bad 
principle  to  be  constantly  side-stepping  issues  by  the 
giving  of  suggestions.  Besides,  it  prevents  the  child  ac- 
quiring the  power  of  immediate  subordination  of  his  own 
desire  to  what  after  all  must  be  done  sometime.  For 
instance,  a  boy  who  cannot  understand  the  rationale  of 
bacterial  infection  is  forbidden  to  take  milk  unless  boiled. 
The  mandate  can  be  enforced  by  the  suggestion  that 
boiled  milk  is  a  delicacy,  and  that  he  is  privileged  in  be- 
ing permitted  to  have  it;  but  this  procedure  is  quite  un- 
necessary when  a  mere  affirmation  should  suffice,  which, 
moreover,  will  prevent  the  danger  of  his  foregoing  the 
privilege,  in  order  to  drink  raw  milk.  The  advantage  of 
assured  obedience  to  authority  is  most  manifest  during 
such  periods  of  emotional  motor  or  intellectual  hyper- 
excitability  as  precede  exhaustion.  They  may  be  com- 
pared to  the  paralytic  secretion  of  the  physiologists. 
Hence  the  more   simple  the  brake   used  the  better,   for 


154  PSYCHOTHERAPEUTICS 

complex  means  of  arrest  only  increase  the  cerebral  activ- 

ity. 

Another  example  of  a  misapplication  of  suggestion 
consists  of  saying  to  a  child,  "  You  are  not  afraid," 
when  he  shows  timidity  in  some  unusual  situation.  The 
child  knows  quite  well  that  the  mere  making  of  the  re- 
mark indicates  a  reason  for  fear;  and  the  real  effect  pro- 
duced is  the  suggestion  of  fear,  which  might  have  been 
avoided  by  assuming  a  matter  of  fact  manner  as  soon 
as  indications  of  hesitancy  or  timidity  were  shown  by  the 
child,  taking  care  at  the  same  time  to  replace  the  unpleas- 
ant affective  mode  by  another,  through  substitution  and 
distraction.  Of  course,  reliance  on  simple  affirmation 
must  be  maintained  by  truthfulness,  and  later  by  reason- 
ableness. 

The  habits  of  accuracy  and  orderliness  may  be  incul- 
cated without  the  danger  of  their  becoming  besetments, 
if  it  is  done,  so  to  speak,  spontaneously  as  a  pleasure, 
and  not  as  a  duty  Calvinically,  that  is,  if  it  is  made 
kinetic  rather  than  inhibitive.  For  example,  a  boy  of 
two  and  a  half  is  asked  to  bring  in  two  balls  with  which 
he  was  playing  in  the  garden,  and  later  to  pick  out  from 
some  others  those  he  brought.  This  exercise  not  only 
cultivates  memory  and  accuracy,  but  the  power  of  per- 
ception of  difference  as  well  as  the  notion  of  responsibil- 
ity and  the  pleasure  in  having  it  recognized. 

A  boy's  whole  world  of  fitness  is  upset  when  unusual 
acts  are  done.  A  boy  of  three  will  allow  no  one  else  to 
touch  the  letters  placed  on  his  father's  plate.  After 
playing  with  his  father  and  wanting  "  more  fun,"  he 
would  not  desist  from  his  demands  when  told  it  was  too 
hard  for  his  father,  replying  "  not  too  hard,"  but  at 
once  did  so  when  told  "  Father  tired."  He  recognized 
this  from  his  mother's  and  his  own  experience  as  a  valid 
excuse  for  stopping. 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     155 

These  habits  become  morally  imperative  (19),  and  are 
very  hard  to  eradicate  in  after  life,  for  they  do  not  de- 
pend upon  clarity  of  conception,  as  is  well  shown  by  the 
fact  that  most  of  us  do  not  act  entirely  in  accord  with 
our  intellectual  convictions,  but  persist  in  regulating  our 
conduct  by  doctrines  long  outgrown.  Hence,  the  im- 
portance of  preventing  the  feeling  of  dependence  by  en- 
couraging the  child's  desire  for  and  pride  in  performing 
tasks  about  the  house  and  garden.  If,  for  instance,  a 
child  is  encouraged  to  put  on  his  own  clothes  under  the 
belief  that  it  is  a  clever  act  or  to  wash  itself,  these  actions 
will  become  automatic,  and  he  will  not  later  have  to  go 
through  the  diflScult  acquisition  of  the  clean  hand  in- 
stinct and  that  of  self-helpfulness   (20). 

The  ineradicability  of  fear  when  inculcated  in  early 
childhood  is  clearly  illustrated  by  the  Southern  lady, 
who  even  in  advanced  age  dared  not  go  alone  into  the 
dark,  although  she  has  long  ceased  to  believe  in  the 
stories  which  first  made  her  afraid  to  do  so.  She  real- 
ized this  so  forcibly  that  she  would  not  permit  her  three 
daughters  to  be  told  any  of  the  alarming  stories  which 
most  Southern  children  learn.  Her  psychoprophylaxis 
resulted  in  the  girls  never  having  known  what  it  meant 
to  be  afraid  in  the  dark.  Indeed,  it  was  the  habit  of 
their  schoolfellows  to  send  them  into  dark  and  eerie 
places  to  show  off  their  powers.  The  tenacity  of  early 
affects  is  again  illustrated  by  the  immovable  depression 
produced  by  the  playing  of  gospel  hymns  on  a  reed  or- 
gan in  the  case  of  a  lady  in  w^hose  childhood  the  Calvin- 
ical  Sunday  had  almost  caused  fear.  The  psychoprophy- 
laxis here  is  obvious  (21).  In  another  case  the  hearing 
of  a  brass  band  invariably  produces  weeping  and  terror. 
This  is  due  to  the  fact  that  such  playing  occurred  dur- 
ing the  horrors  of  the  civil  war. 

In   some   children    (22)    care   is   needed   to   avoid   the 


i 


156  PSYCHOTHERAPEUTICS 

"  hesoin  d'etre  aime/*  the  craving  for  sympathy.  This 
may  be  induced  by  excessive  petting  and  loving  while  a 
child  is  tired  or  after  injury.  It  is  better  to  send  the 
child  to  bed  when  tired  and  to  divert  his  attention  when 
injured.  But  denial  of  sympathy  is  equally  bad,  and  is 
the  cause  of  the  intense  love  hunger  seen  in  many  young 
people  whose  surroundings  have  suppressed  their  natural 
affection. 

It  must  be  remembered  that  the  fundament  of  altruism 
lies  in  the  affect ivity  (23),  and  this  must  not  be  sup- 
pressed, but  must  be  controlled  and  used.  For  instance, 
during  sympathy,  interest  may  be  aroused  and  turned 
into  an  unrelated  channel,  and  thus  used  for  moral  and 
intellectual   teaching  instead  of  being  roughly  ignored. 

These  may  appear  small  matters,  but  they  illustrate 
important  principles,  as  will  appear  when  they  are  ap- 
plied to  the  matter  of  lying  and  the  acquisition  of  the 
sense  of  responsibility  and  right  conduct. 

The  mythomanic  (24)  tendency,  which  is  responsible 
for  so  many  medico-legal  difficulties,  would  be  much 
diminished  by  a  psychoprophjdaxis  addressed  to  the 
afore-mentioned  habit  of  accuracy;  for  the  conduct  indi- 
cated is  merely  a  mode  of  truth  in  act,  which  to  a  child 
precedes  the  significance  of  truth  in  speech.  The  latter 
is  discouraged,  I  believe,  by  mystery  tales,  as  well  as  by 
those  of  voodoo,  though  I  am  aware  that  much  difference 
of  opinion  on  this  point  exists  among  pedagogues.  I 
cannot  enlarge  upon  this  theme,  except  to  point  out  how 
often  mythomanic  manifestations  are  miscalled  hysteria 
by  medical  men  who  have  been  unduly  impressed  by  the 
doctrines  of  Charcot  (25);  whereas,  the  difference  has 
been  clearly  pointed  out  by  Dupre  (26)  and  Babinski 
(27).  The  newspapers  of  the  day  afford  innumerable 
examples  of  the  dishonest  point  of  view  which  eventuates 
in  mythomania.     It  is  almost  entirely  preventable  by  a 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     157 

proper  psychoprophylaxis,  if  not  on  the  part  of  the 
parents,  then  later  and  with  more  difficulty  on  the  part 
of  the  schoolmaster. 

In  this  connection,  I  must  express  the  belief  of  the 
need  for  men  in  the  moral  training  of  boys.  The  best 
elements  of  moral  development  are  inculcated,  not  in  the 
schoolroom,  but  at  play,  in  which  the  masters  must  par- 
ticipate more  or  less :  and  as  at  present  trained,  very  few 
women  are  capable  of  this.  The  revolution  effected  in 
the  habits  or  character  of  the  English  school  boy  by  the 
methods  of  Thomas  Arnold  of  Rugby  (28)  afford  a 
striking  illustration  of  this. 

To  attempt  to  manage  boys  by  religious  sentimental- 
ism  and  softness,  the  woman-and-slave  morality  of 
Neitzsche  (29)  is  to  encourage  hypocrisy  in  the  strong 
and  exaggeration  of  weakness  in  the  feeble.  Of  course 
sympathy  must  be  used,  but  it  must  be  a  manly  one,  re- 
ferring mainly  to  the  forceful  activities  of  the  life  of  a 
normal  boy.  In  this  way  a  self-reliant  character  is  built 
up  by  the  encouragement  of  constant  relation  of  itself 
to  the  welfare  of  a  society  in  the  responsibilities  of  which 
each  boy  has  a  separate  niche  to  fill. 

Than  this  there  is  no  better  prophylactic  against  de- 
spondency, suspiciousness,  and  other  anti-social  feelings 
of  paranoid  type.  By  this  system  of  encouraging 
morality  to  become  constantly  kinetic  and  to  be  thought 
of  and  controlled  by  its  relation  to  others  while  self-re- 
spect is  maintained,  the  hyper-suggestibility  is  restricted 
and  hysteria  prevented. 

Psychasthenic  types  too  are  not  apt  to  develop  in  an 
environment  where  solitariness  is  impossible,  and  where 
the  stresses  are  healthy  and  kinetic,  and  the  emotional 
and  intellectual  appeals  are  of  a  positive  and  clear  com- 
prehensibility.  Hence  the  rarity  of  psycho-neuroses  in 
the  men  who  have  been  trained  in  the  public  schools  of 


168  PSYCHOTHERAPEUTICS 

Great  Britain.  And  their  influence  has  not  cea3ed  here; 
for  the  habits  of  conduct  illustrated  and  brought  into 
prominence  by  Arnold's  boys  have  permeated  the  whole 
national  life,  with  the  result  that  De  Fleury  (30)  has 
been  able  to  comment  with  admiration  upon  the  freedom 
of  the  nation  from  the  psycho-neuroses,  the  study  of 
which  has  given  such  distinction  to  French  neurolo- 
gists. 

Similar  methods  may  be  applied  with  success  even  to 
boys  perverted  by  faulty  environment;  for  instance, 
Tomlins  ("37)  developed  a  thieving  jail  boy  into  a  useful 
citizen  by  reversing  the  mawkish  treatment  he  had  been 
receiving  in  the  reformatory,  and  substituting  a  peremp- 
tory and  rough  method  of  making  him  responsible  for 
certain  duties  and  for  other  boys,  and  showing  surprise 
that  he  did  not  do  better  work  than  he  at  first  showed. 

On  the  other  hand,  there  is  the  case  of  a  girl  in  whom 
intractable  fits  of  temper  were  cured  by  one  display  of 
kindly  sympathy  after  she  had  torn  up  her  books  in  a  fit 
of  rage.  The  prophylaxis  in  each  of  these  cases  meant 
the  saving  of  a  whole  life  from  the  misery  which  would 
have  arisen  in  a  purely  psychogenetic  way. 

The  psychological  insight  which  enabled  the  reflexes 
to  be  "  conditioned  "  in  these  two  cases  is  responsible  for 
these  two  useful  lives. 

Many  a  phobia  or  angoisse  can  be  prevented  by  psychic 
means.  Similar  in  principle  are  the  means  to  be  em- 
ployed against  the  self -distrust  and  diffidence  of  the  psy- 
chasthenic form  of  insufficiency.  The  natural  desire  of 
a  child  to  play  with  its  fellows  will  soon  disappear  if  he 
is  too  slow-witted  to  comprehend  the  game  or  too  clumsy 
to  take  his  due  part,  or  is  constantly  humiliated  by  his 
failure  or  by  the  mockery  of  his  fellows.  Want  of 
capacity  in  some  study  arising  from  the  defect  of  some 
motor  sensorial  or  associational  process  may  produce  a 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     159 

self-deprecatory  or  anxious  attitude  very  unfavorable  to 
healthy  psychic  development  and  most  provocative  of  the 
scrupulosity  of  psychasthenia. 

The  method  of  conditioning  the  reflexes  is  illustrated 
most  clearly  by  human  beings  in  cases  of  sexual  perver- 
sion where  some  artificially  introduced  element  becomes 
the  efficacious  provoker  of  future  sexual  desire,  or  at 
least  satisfaction.  The  genesis  of  the  felich  constitutes 
the  conditioning  of  the  sexual  reflex  in  that  person. 

The  whole  element  of  the  sexual  element  in  the  causa- 
tion of  the  psycho-neuroses  is  too  long  to  discuss  here. 
I  must,  however,  deplore  the  difficulties  thrown  in  the  way 
of  the  study  of  these  very  important  problems  of  psycho- 
prophylaxis  by  the  unwillingness  of  some  observers  to 
investigate  the  sexual  life  of  their  patients.  To  estab- 
lish a  solid  psychoprophylactic  doctrine  we  need  accurate 
information,  and  the  scientific  search  for  such  informa- 
tion must  not  allow  itself  to  be  hampered  by  national 
prudishness.  It  is  this  noli  me  tangere  perversion  of 
morality  which  arrogates  to  itself  the  exclusive  title  of 
morality  which  is  responsible  for  much  of  the  prurient 
attitude  of  the  young  towards  sexual  relationship. 

What  shall  we  think  of  a  civilization  which  permitted 
a  highly  respected  woman  physician  of  twenty  years' 
standing  to  be  placed  in  jail  for  having  written  a  book 
instructing  young  women  upon  sexual  hygiene?  This 
actually  happened  less  than  five  years  ago  in  Chicago. 
Such  an  attitude  fosters  ashamedness  in  the  young;  and 
shame  of  the  bodily  functions  as  we  know  frequently 
dominates  the  field  of  consciousness  of  a  psychasthenic. 
An  adolescent  who  has  been  discouraged  from  discussing 
or  understanding  the  phenomena  even  of  his  own  sexual 
life  and  taught  to  regard  them  as  diff*erent  in  kind  from 
other  facts  of  personal  function  and  hygiene  is  sadly 
handicapped  in  the  difficult  process  of  somato-psychic  or. 


160  PSYCHOTHERAPEUTICS 

allo-psychic  adjustment  in  that  difficult  period  of  his 
life. 

Similar  animadversion  may  be  made  against  what  is 
now  less  common  —  the  state  of  apprehension  and  terror 
induced  by  religious  teachings  founded  upon  the  doctrine 
of  man's  inherent  evil  nature  and  damnableness.  A  re- 
search by  Coe  showed  that  less  than  ten  years  ago  a 
very  large  percentage  of  college  students  had  suffered 
severely  from  the  spiritual  agonies  of  the  attempt  to 
reconcile  their  dawning  knowledge  of  the  universe  with 
the  inadaptive  and  injurious  doctrines  they  had  been 
taught  in  the  name  of  religion  and  morality. 

Now  it  is  very  simple  to  forestall  such  morbid  reaction 
by  directing  the  activity  of  such  children  into  channels 
for  which  they  show  aptitude.  From  the  feeling  of  ac- 
complishment and  triumph  thus  engendered  the  child  will 
gradually  learn  to  adjust  himself  to  difficulties  which 
mental  prepossessions  and  inertia  would  have  rendered 
impossible  to  overcome.  A  delusion  of  persecution  so 
often  fertile  in  dangerous  reactions  has  really  its  source 
in  a  mistrust  and  suspiciousness  which  might  have  been 
prevented  or  removed  by  the  self-satisfaction  coming 
from  the  fulfilled  desire  of  productive  activity.  The  de- 
lusion is  essentially  a  defense  reaction  against  the  feeling 
of  self-distrust.  Such  feeling  is  powerfully  conduced 
to  by  cultivating  in  children  a  pride  not  consonant  with 
their  true  relatien  to  others ;  for  the  social  activities  of 
such  children  will  be  contaminated  by  an  exaggerated 
self-respect  which  will  necessarily  be  constantly  wounded, 
whence  an  inevitable  withdrawal  from  social  activities 
which  do  not  minister  to  their  pride,  and  therefore  an 
ever-increasing  seclusion  which  is  more  and  more  domi- 
nated by  suspicious  inferences  from  innocent  words  and 
acts  of  others  and  brooding  thereupon  until  this  idea- 
tional-emotional    complex    dominates    and    becomes    the 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     161 

character  of  the  person  and  refractory  to  intervention; 
but  the  psychoprophylaxis  would  have  been  simple,  and 
is  obvious. 

The  gastric  neuroses  are  a  striking  example  of  the 
non-use  of  psychoprophylactic  power  by  medical  men: 
for  the  great  majority  of  these  cases  occur  as  the  result 
of  the  suggestions  of  medical  men  while  prescribing  for 
patients  suffering  from  temporary  indigestion  (33)  or 
by  the  indirectly  gained  notions  of  medical  origin  with 
regard  to  eating  and  diet.  Again,  recent  work  has 
shown  the  difference  between  tic  and  true  chorea,  and 
also  that  the  latter,  now  clearly  shown  to  be  an  organic 
disease  (37)  may  begin  by  intellectual  and  emotional 
perturbations  long  before  the  motor  areas  are  affec- 
ted. 

The  only  practical  way  of  detecting  these  early  condi- 
tions is  through  medical  inspection  of  school  children  by 
trained  neurologists  whose  knowledge  of  physical  and 
mental  test  signs  will  anticipate  many  a  breakdown,  be- 
sides removing  from  the  other  children  the  contagion 
which  habit-spasm  and  choreiform  movements  are  known 
to  exercise  on  their  plastic  minds.  As  a  matter  of  fact 
the  co-operation  which  should  be  sought  is  much  less 
that  of  the  priest  than  that  of  the  teacher  of  the  young. 
We  can  hope  to  influence  him  to  a  scientific  attitude  to- 
ward the  biological  phenomena  with  which  he  deals;  be- 
sides which  the  help  in  managing  difficult  and  neurotic 
children  which  he  gains  from  neurological  advice  makes 
him  very  ready  to  welcome  it,  as  my  experience  shows. 

And  indeed  pedagogues  themselves  have  noticed  the 
need  of  medical  psychoprophylaxis.  Thus  Swift  (loc, 
cit.)  says,  "  Half  an  hour's  observation  of  pupils  at  their 
school  work  will  convince  one  skilled  in  interpreting  nerve 
signs  that  nervous  disorders  have  become  so  common  as 
to  menace  our  national  health,  and  the  significance  of 


162  PSYCHOTHERAPEUTICS 

this  for  education  has  been  too  generally  ignored." 
And  again  further,  "  It  is  unfortunate  that  instincts  are 
so  frequently  the  child's  only  defense  against  the  peda- 
gogical enlightenment  (sic)  medical  supervision  cannot 
fully  meet  the  need  unless  a  nervous  affection  is  detected 
in  its  incipiency;  so  the  teacher  must  be  taught  about 
the  early  signs,  so  as  to  call  in  a  physician  to  prevent 
aggravation  by  the  continued  irritation  of  test  and  ex- 
amination." 

As  desirable  would  be  the  teaching  of  the  mothers  to 
form  healthy  emotional  habits  in  their  children.  The 
happy-go-lucky  absolutism  which  so  often  assorts  itself 
as  capacity  is  sadly  defective  as  such  a  guide  for  hesi- 
tating childhood.  The  management  of  the  mind  and  the 
emotions  into  a  morality  constitutes  the  most  difficult 
study  and  art.  But  it  can  hardly  be  expected  that 
fortitude  can  be  inculcated  by  a  mother  who  has  not 
herself  shown  it  sufficiently  to  even  attempt  to  under- 
stand the  biological  laws  upon  which  depend  the  reac- 
tions of  the  nervous  system  which  we  call  conduct,  for 
the  ethics  taught  to  most  children  is  a  vestige  of 
medievalism  conspicuous  for  its  poverty  in  such  criteria 
of  modern  civilization  as  justice,  liberty,  courtesy,  altru- 
istic sympathy.  The  child's  natural  good  impulses  are 
checked  and  twisted;  when  his  reasoning  from  cause  to 
effect  is  not  neglected  or  obstructed,  he  is  thus  confused 
and  finally  often  discouraged  into  sadness  or  indifference, 
becoming  as  a  man  either  despondent  or  happy-go-lucky, 
with  either  no  morality  or  one  of  words  only,  which  has 
no  efficacy  in  preventing  maladjustment. 

But  a  morality  which  is  really  active  instead  of  being 
merely  received  on  faith  becomes  a  part  of  a  boy's  char- 
acter and  is  carried  out  in  his  conduct.  It  intertwines 
with  his  every  thought  often  quite  unconsciously.  Sug- 
gestions contrary  to  this  trend  are  then  automatically 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     163 

repulsed,  and  we  secure  reliability  of  conduct;  and  so- 
cially speaking  that  power  of  prediction  which  gives 
security  in  man's  relationship  with  man. 

Now  this  may  appear  hardly  a  medical  but  more  a 
sociological  matter;  but  there  is  no  difference  of  kind 
between  a  perversion  of  conduct  which  we  call  criminal, 
that  is,  anti-social,  and  an  aberration  proceeding  from 
ideas  which  we  call  hysterical.  The  false  belief  that 
one's  limbs  are  incapable  of  locomotion  or  the  comfort- 
able and  cherished  feeling  that  one  is  an  invalid  and  un- 
able to  support  one's  self  are  both  anti-social  attitudes, 
in  whatever  good  faith  they  are  assumed. 

Now  their  prevention  as  well  as  their  cure  is  the  pre- 
rogative and  duty  of  medical  science,  which  is  called 
upon  to  distinguish  from  the  aberrations  of  conduct  due 
to  the  change  in  the  secretions,  and  the  nervous  system 
those  due  to  aberrant  notions.  And,  nowadays,  as  this 
symposium  shows,  we  have  to  apply  the  remedy,  not  only 
to  the  former,  but  the  latter  in  supplementing  the  activi- 
ties of  the  pedagogue  and  priest  with  the  special  means 
the  psychiatrist's  training  permits ;  that  is  to  say,  when 
a  pathological  type  of  reaction  has  been  constituted  by 
the  hurtful  suggestions  of  a  faulty  environment,  it  is 
the  doctor's  province  to  eradicate  the  hurtful  sugges- 
tions and  to  emplant  a  habit  of  mind  tending  for  the 
good  of  society  and  refractory  to  suggestions  contrary 
to  that  object.  For  a  close  analysis  shows  that  the  real 
cause  of  most  so-called  "  nervous  prostration  "  is  failure 
of  adjustment  to  environment,  and  is  psychogenetic.  A 
rest  cure  in  itself  is  inefficacious,  but  gives  the  doctor 
the  opportunity  to  re-educate  the  perverted  trends  of 
the  patient's  disposition.  Before  reaching  the  neurolo- 
gist, a  patient  has  been  "  suggestioned  "  ad  nauseam: 
and  such  empirical  therapy  has  failed,  as  has  the  inju- 
dicious appeal  to  his  will  power  already  exhausted  by  the 


1645  PSYCHOTHERAPEUTICS 

complexities,    social    and   professional,    which   have    con- 
tributed to  his  failure  of  adjustment. 

To  arrest  a  morbid  train  of  thought  and  set  a  mind  at 
rest  is  an  art  requiring  knowledge  and  skill.  Its  at- 
tempt by  untrained  men  has  been  even  more  disastrous 
than  the  work  of  the  tyro  in  gynaecology;  for  it  is  the 
direct  cause  of  the  rise  of  Christian  Science,  Emmanuel- 
ism,  and  such  cults.  Happily,  a  body  of  experts  in  psy- 
chopathology  is  now  counteracting  their  injurious  influ- 
ence: for  an  affectation  of  knowledge  will  not  supply  the 
public's  demand  for  real  psychic  treatment.  But  we  re- 
quire greater  facilities  for  instructing  medical  men  in 
the  principles  of  psychopathology  and  therapeutics ;  and 
proper  wards  and  out-patient  clinics  under  competent 
teachers  should  be  provided,  at  least  in  every  large  city. 

REFERENCES 

1.  Grasset.    Therapeutique    des    Maladies    du    Systeme    Nerveux. 

Paris,  1907. 

2.  The   Huxley   Lecture,    Brit.   Med.   Jour.,   1906. 

3.  See  Morton  Prince.    The  Unconscious,  Joue.  Abnor.  Pst.,  1909, 

Dec.    Friedmann  and  Gierlich  Studies  in  Paranoia.    Trans. 
Nervous  and  Mental  Series,  N.  Y.,  1908. 

4.  Suggestion    and    Persuasion.    Alienist    and    Neurologist,    1909, 

May. 

5.  Rev.  Neurologique.     1907. 

6.  Camus  et  Pagniez.     Isolement  et  Psychotherapie.    Paris,  1904. 

7.  The  Relation  of  the  Med.  Prof,  to  the  Psychotherapeutic  Move- 

ment.    Boston  Med.  Jour.,  1908. 

8.  Riv.  Sper.  di  Phren.  et  Psy.,  1908. 

9.  Janet,  Les  Oscillations  du  Niveaux  Mentale  Congrfes  de  Rome, 

1904. 

10.  Williams,  The  DiflFerential  Diagnosis  between  Neurasthenia  and 

Some  Affections  of  the  Nervous  System,  for  which  it  is  often 
mistaken.     Archives  of  Diagnosis,  1909,  Jan. 

11.  Williams.     Hints     on     Psychotheraphy.    Monthly     Cyclopedia, 

1908. 

12.  Lemons  Cliniques.     1907.     (Unpublished.) 

13.  Mind  in  the  Making.     New  York,  1908. 

14.  Williams,    Discussion    on    Responsibility    of    Hysteria.    Contes 

rendues  Congr^s  de  Lille,  1906. 


PSYCHOPROPHYLAXIS  IN  CHILDHOOD     165 

15.  La  Suggestibility.    Paris,  1897. 

16.  Jastrow.    Fact  and  Fable  in  Psychology.    N.  Y.  and  London, 

1907. 

17.  See  O'Shea,  The  Dynamic  Factor  in  Education,  1904.     N.  Y. 

Archibald,  The  Power  of  Play.    London,  1908. 

18.  Raymond  et  Janet,  Les  Obsessions  et  la  Psychasthenic.    Paris, 

1903. 

19.  Leuba.    The    Nature    of   the   Moral    Imperative,    Amer.    Jour. 

Psy.,  1897. 

20.  See    Williams,    The    Psychological    Bases    of    Inebriety.    New 

York  Med.  Jour.,  1909,  April.    Also  Pedag.  Seminary,  1909, 

21.  See  White,  Theory  of  the  Complex,  Interstate  Med.  Jour.,  1908, 

April.    Morton  Prince,  loc.  cit.  Chap.  II. 

22.  Raymond  et  Janet,  loc.  cit. 

23.  Spencer,  The  Data  of  Ethics. 

24.  Dupr6,  La  Mythomanie.    Paris,  1906. 

25.  See  such  current  text  books  as  SaviUe,  Church,  and  Petersen. 

26.  Loc.  cit, 

27.  Ma  Conception  de  THysterie.    Paris,  1906.    La  Demembrement 

de  I'Hysterie.    Semaine  M6dicale.    1909. 
27a,  The    Trend    of   the    Clinician's    Concept    of   Hysteria.    Boston 
Med.  and  Surg.  Jour.,  1909.    March  25. 

28.  Sec  Tom  Brown's  School  Days  and  Numerous  Lives. 

29.  Mancken,  The  Philosophy  of  Neitzsche.    New  York,  1908. 

30.  Le  Figaro.    Paris,  1906. 

31.  Communicated  verbally. 

32.  See  Williams.    The  Most  Frequent  Cause  of  Nervous  Indiges- 

tion, Jour.  Abnor.  Psy.,  1909,  Feb.    Also  Amer.  Med.,  1909, 
April.    Old    Dom.    Jour.,    1908,    Nov.    D6g6rine    Les    Fausse 
Gastropaths,  Presse  Med.,  1906. 

33.  Le  R61e  du  Medecin  en  errant  ou  en  maintainant  par  ses  Sug- 

gestions Maladroites  les  Maladies  produites  par  I'lmagina- 
tion.  Congrfes  des  Neurologists  k  Lille,  1906.  Trans.  Amer. 
Med.,  1908,  Aug. 

34.  Steherback,  Arch,  de  Neur.,  1709. 

35.  The  Psychology  of  the  Spirtiual  Life,  Chicago  &  New  York, 

1904, 

36.  Meige  et  Feindehl,  Les  Tics  et  leurs  Traitements.    Paris,  1901. 

Williams,  Differential  Diagnosis  of  Tics  &  Spasms  Via 
Semi-Monthly,  1908. 

37.  Payne  et  Poynton,  The  Etiology  of  Chorea,  Brit.  Med.  Jour., 

1906. 

38.  Burr,  President's  Address,  Jour.  Nery.  et  Ment  Disease,  1908. 


CHAPTER  NINE 

The  Relation  op  Character  Formation  to 
Psychotherapy 

by  james  j.  putnam,  m.d. 
Processor  Emeritus^  Harvard  Medical  School 

MY  object  in  this  paper  is,  first,  to  indicate  the 
place  of  a  study  of  character  in  a  scheme  of 
psychotherapy ;  next,  to  delfine  what  we  mean  by 
character;  and  lastly,  to  point  out  how  far  it  is  reason- 
able to  expect  to  modify  character  and  under  what  prin- 
ciples this  is  to  be  attempted. 

The  word  character  will  be  here  employed  in  its  usual 
double  sense;  first,  as  in  describing  the  prevailing  ten- 
dencies of  a  man's  life  without  reference  to  their  value 
as  regards  the  securing  of  results;  next,  as  a  sort  of 
estimate  of  value  —  intellectual,  esthetic,  moral,  voli- 
tional,—  of  these  various  tendencies. 

In  accordance  with  the  former  of  these  two  meanings 
we  might  speak  of  a  person  as  being  sanguine  or  volatile, 
stolid  or  visionary,  dependent  or  independent,  etc.  In 
accordance  with  the  second  meaning  we  might  speak  of 
him  as  being  a  man  "  of  character,"  meaning  thereby 
that  he  was  of  "  fine  "  or  **  strong "  character.  It  is 
needless  to  say  that  these  terms  "  fine  "  and  "  strong  " 
have  a  relative  significance,  but  into  this  consideration 
we  need  not  enter  here.  The  antithesis  between  these 
two  meanings  of  the  word  character  is  best  shown  when 
we  say  of  a  person,  as  we  clearly  may,  that  his  character 
is  to  be  defined  as  consisting  in  an  absence  of  character. 
It  will  be  seen  that  the  various  terms  hitherto  used  for 

16^ 


CHARACTER  FORMATION  167 

the  designation  of  character  will  have  to  give  place  to 
others  of  more  exact  scientific  meaning,  or  else  to  get 
themselves  reclothed  with  the  connotations  of  a  new  sort, 
but  the  word  character  is  likely,  none  the  less,  to  preserve 
its   double   signification. 

It  must  be  evident  to  every  one  who  looks  closely  at 
the  facts,  that  the  therapeutic  efforts  of  those  physicians 
who  concern  themselves  especially  with  the  study  of  the 
functional  psychoses  have  been  rapidly  developing  on 
new  and  interesting  lines.  The  neurologists  of  the  pres- 
ent day  tend  less  and  less  to  treat  the  nervous  invalids 
entrusted  to  their  care  in  accordance  with  the  principles 
of  a  narrow  militarism  or  as  subjects  for  cajoling,  and 
more  and  more  as  reasonable  beings  possessed  of  con- 
sciences and  independent  wills  and  capable  of  intelligent 
co-operation.  In  proportion  as  our  knowledge  of  the 
mental  life  has  become  deeper  and  more  accurate  there  ^ 
has  been  a  growing  tendency  to  seek  further  and  further 
for  the  causes  of  distressing  mental  symptoms,  whether 
these  causes  lie  in  the  environment  of  the  patients  or  in 
the  habits  and  instincts  and  experiences  dating  back  to:  - 
the  years  of  childhood  or  expressed  in  inherited  physical 
traits.  Hand  in  hand  with  these  tendencies  towards  a 
more  searching  analysis  of  symptoms  with  reference  to 
this  origin  there  has  come  a  willingness  to  undertake  a 
modification  of  the  mental  mechanism  such  as  was  not 
characteristic  of  the  therapeutic  efforts  of  earlier  days. 
Success  in  these  efforts  constitutes  the  triumphs  of  mod- 
ern neurological  practice.  The  more  complex  of  these 
methods  might  be  described  as  constituting  the  major  - 
surgery  of  this  form  of  therapeutics,  since  to  utilize  them 
at  their  best  requires  both  skill  and  insight  and  willing- 
ness to  expend  a  vast  amount  of  time  for  the  accomplish- 
ment of  the  results.  The  modern  practice  has  come  more 
and  more  to  deserve  the  name  of  education.     Less  effort 


1^  PSYCHOTHERAPEUTICS 

is  now  made  to  shunt  out  the  critical  powers  and  instincts 
of  our  patients ;  greater  effort  to  lead  them  into  paths 
of  intelligent  insight.  Hypnosis  is  less  often  used  for 
the  purposes  of  pure  suggestion,  while  the  induction  of 
hypnoid  states,  for  the  purposes  of  analysis,  and  through 
analysis,  of  treatment,  has  become  more  common,  and 
even  this  method  is  giving  place  to  kinds  of  mental  prob- 
ing in  which  the  patient  takes  a  conscious  and  a  willing 
part.  "  Isolation  cures  "  and  "  work  cures,"  valuable 
as  they  are,  are  found  to  yield  their  best  results  when 
made  parts  of  a  broad  system  of  education.  The  final 
aim  of  the  isolation  should  be  social  life,  in  its  best  sense, 
and  work  done  by  the  invalid  should  lead  to  work  done 
for  the  social  welfare.  In  the  same  sense,  rules  of  living 
are  found  to  yield  their  best  results  when  made  sub- 
servient to  principles  of  living,  and  success  in  treatment  j,- 
is  estimated,  not  so  much  by  the  disappearance  of  symp- 
toms as  by  the  appearance  of  a  thoughtful  individual, 
liable  to  fail,  but  competent  to  use  his  failures  in  the 
interests  of  progress. 

It  is  on  the  basis  of  a  firm  belief  in  the  value  of  these 
new  forms  of  inquiry  into  the  mental  life  that  the  fol-<^ 
lowing  remarks  on  character  are  offered.     The  object  of 
these  new  and  searching  inquiries  is  to  make  us  intimately    ^ 
acquainted  with  the  nature  of  the  man  with  whom  we  ' 
have  to  deal.     But  it  is  precisely  in  attempting  to  define 
his  character  that  we  put  this  knowledge  to  the  best  test. 
JiFoT  the  character  is  the  epitome  of  the  man.     It  is  no 
longer  enough  to  characterize  a  man  as  "  self-centered," 
"  irresolute,"  "  dominated  by  envy,  suspicion,  jealousy  "; 
or,  on  the  other  hand,  as  a  person  of  "  fine  "  or  "  strong  " 
character,'  as  if  we  had  the  right  to  assume  that  we  had 
thereby  added  something  material  to  our  knowledge  of 
him,  in  a  scientific  sense.     If  the  person  in  question  is 
not  unified,  in  respect  to  his  mental  states,  but  "  disso- 


I 


CHARACTER  FORMATION  169 

ciated,"  as  through  strong  emotional  strain  or  through 
even  moderate  emotional  strain  acting  on  tendencies  al- 
ready physiologically  unstable;  in  other  words,  if  he  is 
a  "  hysteric,"  with  contracted  field  of  mental  vision,  then 
of  course  he  is  self-centered,  and  the  physician's  duty  is, 
not  to  blame  him  but  to  recognize  him,  to  see  that  he  is 
not  misjudged,  and  if  possible  to  cure  hini. 

The  truth  is  that  ever  since  the  day  when  medical 
observation  first  began  to  intrude  itself  definitely  into 
the  field  of  psychology,  a  new  vocabulary  and  new  syn- 
onyms have  been  more  and  more  demanding  recognition. 

It  is  as  true  in  the  mental  as  it  is  in  the  physical  field 
that  "  disease  is  but  health  under  altered  conditions  "  {^ 
and  that  many  a  moral  ban  of  the  conventional  social 
judge  will  have  to  give  way  before  a  truer  re-statement 
of  the  facts  than  our  ignorance  had  known.  So  far  as 
we  can,  then,  let  us  in  the  future  strive  to  infuse  new 
meaning  into  our  conceptions  of  the  terms  character 
and  characters.  Let  us  be  more  chary  of  roughly  group- 
ing men  as  bad,  selfish,  or  weak  in  character,  and  more  1/ 
ready  to  search  diligently  for  the  exact  influences  that 
made  them  what  they  are.  Nothing  happens  by  pure 
chance. 

The  most  fruitful  work  in  the  way  of  mental  analysis,*? 
and  therefore  incidentally,  of  character  analysis,  has  I 
been  that  which  has  centered  round  the  observations  of 
Janet,  of  Bergson,  and  of  Freud  —  to  mention  only  a 
few  of  the  foremost  names  —  and  the  main  object  of 
their  researches  has  been  to  discover  the  influence  of  the 
unseen  mental  life.  Most  people  feel  as  if  they  could 
point  distinctly  to  the  influences  that  have  shaped  their 
characters  and  conduct.  But,  in  fact,  the  necessity  of 
action,  the  necessity  of  social  conformity,  force  our 
choices,  narrow  our  vision,  and  compel  mental  conflicts  / 
which  take  a  silent  part  in  shaping  the  habits  and  tenden- 


170  PSYCHOTHERAPEUTICS 

cies  of  response  that  we  call  our  characters.  Thus  the^ 
lives  even  of  the  best  men  are  compromises,  adaptations 
for  more  or  less  special  ends.  It  has  often  been  pointed 
out  of  late  years  what  an  important  part  emotion  and 
emotional  interests  play  in  determining  the  current  of 
our  thought  and  actions,  and  that  when  a  painful  emo- 
tion is  suppressed  it  is  apt  to  carry  with  it  a  cluster  of  '^ 
memories  into  a  species  of  oblivion.  But  this  grouping 
of  mental  processes  around  emotions,  which  gives  a  tend- 
ency to  our  thoughts  to  recur  in  "  constellations  "  rather 
than  isolated,  one  by  one,  typifies  the  construction  of  our 
mental  lives  in  general.  It  is  therefore  theoreticallyV-^ 
explicable  that  the  tendency  to  the  formation  of  double 
or  multiple  lives,  or  to  what  has  been  called  dissociation 
and  reassociation  on  new  lines,  should  occur  to  a  certain 
extent  not  only  in  hysteria,  but  under  conditions  com-t  ' 
monly  called  normal.  It  can  be  understood  on  the  same 
principle  how  a  person's  character  may  be  double,  and 
inasmuch  as  our  subconscious  mental  lives,  those  por- 
tions of  ourselves  which  we  exclude  from  the  focus  of 
our  immediate  interest,  are  far  more  comprehensive  than 
our  lives  of  self-conscious  awareness,  it  is  also  comprehen- 
sible that  large  tendencies  and  even  personalities,  each 
expressible  in  condensed  form  as  character,  should  exist 
side  by  side  and  affect  our  conduct  without  being  readily 
observable  in  and  for  themselves. 

Equally  important  with  this  principle  of  dissociation 
and  reassociation  is  the  principle  of  the  persistence  into 
later  years,  of  mental  twists  and  habits  formed  in  child- 
hood, not  in  their  own  form,  but  strangely  altered  and 
concealed.  The  principle  itself  is  familiar  enough,  but 
it  is  to  the  keenness  and  genius  of  Freud  that  we  owe  its 
working  out  in  ways  which  must  indeed  be  tested  further, 
but  which  are  certain  to  be  of  great  utility,  both  in  help- 
ing us  to  understand  character  and  to  treat  its  morbid 


CHARACTER  FORMATION  171 

modifications.     Underneath  the  cloak  of  fears   and  ter- 
rors we  are  taught  by  this  writer  to  seek  for  the  hidden  ^^ 
element  of  desire,  and  are  given  directions  for  the  search 
which  demand  our  thoughtful  consideration. 

It  might  appear  from  these  remarks  that  I  regard  the 
psychological  method  as  the  only  one  likely  to  help  us 
in  this  study  of  character  and  its  treatment,  and  like- 
wise that  the  sole  use  of  the  tendencies  to  reaction  that 
deserve  the  name  of  character  is  to  secure  an  adaptation 
to  a  given  environment.  But  this  is  by  no  means  true. 
In  the  first  place  our  knowledge  has  not  yet  reached  so 
far  but  that  our  instinctive  judgment  outstrips  it  still 
at  many  points.  Try  as  we  may  to  explain  character  by 
studying  its  genesis,  it  has  still  a  meaning  which  is  cer- 
tain to  elude  our  critical  inquiry,  yet  which  we  strongly 
feel.  In  the  next  place,  the  explanation  of  the  progress 
of  vital  processes  as  here  hinted  at,  does  not  supply  the 
meaning  of  life  nor  the  motives  for  living.  It  is  one  of 
the  great  mistakes  of  modern  science  to  assume  that  we 
can  get  on  without  interesting  ourselves  in  these  matters. 
It  is  widely  thought  that  a  man  need  not  speculate  about 
his  origin  and  his  destiny,  or  upon  the  obligations  of 
loyalty  furnished  by  considerations  of  these  sorts. 
These  sentiments  I  by  no  means  share.  I  think,  on  the 
contrary,  that  physicians  are  as  much  bound  to  study 
philosophy  as  psychology  and  to  carry  their  patients 
with  them  so  far  as  it  is  practicable  to  do  so,  through 
this  path.  Then,  as  regards  the  matter  of  adaptation, 
I  believe  it  is  only  just  to  speak  of  character  as  stand- 
ing for  adjustments  to  the  environment  if  we  are  ready 
to  define  our  environment  in  a  broader  way  than  it  is 
usually  defined.  We  are  surrounded  by  a  world  of  spirit 
just  as  obvious  as  the  world  of  matter  to  any  one  who 
has  the  knowledge  and  willingness  to  probe  beneath  the 
surface,  and  possessed  of  a  reality  more  basal  than  any 


I 


172  PSYCHOTHERAPEUTICS 

reality  that  it  is  possible  to  assign  to  the  material  world, 
considered  in  and  for  itself. 

Excellence  of  character,  then,  is  definable  with  refer- 
ence to  the  degree  to  which  it  represents  all  the  different 
portions  of  a  person's  history  and  nature,  and  may  be 
defined  as  of  a  better  sort  the  more  completely  it  implies 
a  unification  of  the  powers,  physical,  and  mental,  of 
which  he  is  composed,  and  the  more  it  indicates  that  he 
is  capable  of  adapting  himself  to  a  variety  of  environ- 
ments. But  these  environments  must  not  be  purely  of 
a  material  sort.  The  individual  possessed  of  the  best 
form  of  character  must  be  suited  not  alone  to  the  en- 
vironment which  he  sees  but  to  an  environment  which  he 
imagines  with  the  vision  of  an  intelligent  and  critical 
idealist. 

The  treatment  of  patients  from  the  point  of  view  of 
character  is  then  identical  with  the  treatment  of  them  as 
partial  neurasthenics,  hysterics,  or  psychasthenics,  etc., 
on  the  one  hand,  and  as  individuals  standing  in  need  of 
a  broader  vision,  on  the  other. 

A  man's  character  is  not  something  superadded  to  his 
other  qualities,  something  capable  of  existing  independ- 
ently and  to  be  recognized  in  and  for  itself.  It  is  only 
picturesquely  and  for  convenience'  sake  that  we  speak  of 
character  as  of  a  sort  of  seal  stamped  on  the  record  of  a 
person's  life,  a  diploma  of  success  or  failure,  granted 
from  without.  Each  one  of  a  man's  acts  is  the  outcome 
^  of  all  the  acts  that  have  preceded  it  in  the  past,  plus  a 
quality  derived  from  free  choice.  This  free  choice  is 
based  partly  on  a  divination  of  the  future,  or  —  to  speak 
more  accurately  —  on  a  half-conscious  recasting  of  the 
present  in  terms  of  a  wider  order  than  that  which  is  rep- 
resented by  experience  alone.  We  outside  observers  com- 
pare and  contrast  a  series  of  such  acts  and  when  we  find 
that  there  are  features  common  to  them  all  or  to  large 


CHARACTER  FORMATION  173 

groups  of  them,  we  collect  and  name  these  common  fea- 
tures, and  thus  assume  for  them  by  implication  a  sepa- 
rateness  of  existence  which  in  fact  they  cannot  claim. 
In  reality  every  act  represents  an  indivisible  effort  of 
the  actor's  mind,  and  it  is  only  by  abstraction  that  we 
assign  a  definite  portion  of  a  given  result  to  the  man's^ 
character. 

From  a  single  base  an  infinite  number  of  triangles  can 
be  drawn,  and  all  will  have  something  in  common  though 
each  may  be  conceived  of  as  independent  of  the  rest. 
And  so  may  the  same  basal  elements  of  character  per- 
meate an  infinite  number  of  single  acts,  each  of  which 
has  an  autonomy  of  its  own. 

When  we  state,  then,  in  respect  to  a  person's  intellec- 
tual, emotional,  or  volitional  life,  that  it  has  this  or  that 
character,  we  render,  primarily,  a  judgment  based  on 
observation  of  his  conduct  under  various  conditions. 
But  this  judgment  contains  also  an  implied  belief  that 
his  conduct  owed  its  existence  to  the  influence  of  certain 
sets  of  causes.  Thus  when  we  speak  of  a  person  as  being 
of  "  good  "  character  or  as  being  "  able,"  or  "  courage- 
ous," or  the  reverse,  we  instinctively  think  of  him  as  hav- 
ing inherited  certain  traits  or  as  having  been  exposed  to 
influences  which  helped  to  make  him  habitually  act  in 
certain  ways. 

Both  these  elements  in  our  judgments  of  a  person's 
character  are  subject  to  considerable  error,  but  this  ap- 
plies especially  to  the  second  element,  that  which  deals 
with  the  genesis  of  character. 

The  statement  of  a  person's  character  thus  assumes  to 
give  an  epitome  of  his  past  and  a  forecast  of  his  future. 
A  forecast  of  his  future,  because  in  the  acts  and  atti-i 
tudes  of  every  individual  something  of  his  own  divination 
of  his  future  is  contained  and  actually  exerts  an  effective 
force,  and  thus  communicates  a  portion  of  the  tendenciea 


i ;  i  PSYCHOTHERAPEUTICS 

that  make  up  his  character.  It  is  just  this  power  to 
penetrate  the  future  that  measures  and  constitutes  a 
man's  free  will. 

J,  ^  It  follows  from  what  has  just  been  said  that  it  is  only 
as  a  figure  of  speech  that  it  is  justifiable  to  speak  of  at- 
tempts to  form  character  as  in  the  sense  of  seeking  to 
reach  a  clearly  defined  goal.  If  a  valid  character  is  the 
outcome  of  valid  acts  done  in  the  past,  modified  at  every 
turn  by  free  choices  made  in  the  interests  of  a  higher 
order,  then  we  can  gain  character  only  in  one  way, 
namely,  through  our  acts.  It  would  be  an  ignoble  effort, 
and  one  certain  to  defeat  itself,  to  attempt  to  gain  the 
favorable  judgment  of  others  as  a  species  of  personal 
asset,  in  any  other  mode  than  this.  The  habit  or  tend- 
ency to  react  in  a  desirable  manner  is  formed  as  the  re- 
sult of  a  long  series  of  thoughts,  purposes,  and  senti- 
ments genuinely  entertained  and  efforts  effectively  car- 
ried out.  A  person  who  would  reach  the  same  result, 
and  who  would  be  recognized  as  having  reached  it,  should 
seek  it  by  following  a  similar  road  in  the  same  genuine 
spirit.  But  this  road  is  not  one  mapped  out  in  advance. 
Each  person  builds  it  as  he  goes,  through  acting  out  his 
own  nature.  Neither  can  the  goal  be  foreseen  except  in 
very  general  terms.  As  the  needs  change  so  do  our  acts 
and  purposes  shift  and  become  modified,  and  so  likewise 
our  character.  For  a  man's  character  is  a  sort  of  com- 
posite photograph  of  his  life.  The  portrait  is  bound  to 
be  genuine,  whether  the  elements  to  be  portrayed  repre- 
sent genuineness  and  consistency  in  the  ordinary  moral 
or  intellectual  sense,  or  lack  of  genuineness  and  incon- 

"i  sistency,  effectiveness  or  ineffectiveness. 

/  The  more  symmetrical,  unified,  and  adequate  a  man's 
development  has  been,  the  more  consistent  is  his  conduct. 
On  the  other  hand,  not  only  the  best  in  each  person  but 
also  the  worst  and  the  indifferent  elements  in  him  neces- 


CHARACTER  FORMATION  176 

sarily  play  a  hand  in  this  game.  Fortunately,  in  the  con- 
tinual melting  up  and  remelting  that  goes  on  within  the 
crucible  of  progress,  the  worst  may  be  made  eventually 
an  element  of  the  best,  but,  for  the  time  being,  if  it  be- 
comes a  fixed  habit  to  be  trivial  that  habit  will  be  faith- 
fully represented  in  a  person's  character,  for  this  repre- 
sents the  master  habit  of  his  habits,  the  master  tendency 
of  his  tendencies.  There  is  no  room  for  deception  in  the 
judgments  of  that  court. 

A  person's  character  is,  however,  not  always  just  the 
same.  It  presents  itself  under  different  forms,  corre- 
sponding to  the  changing  aspects  of  his  personality  and 
his  moods,  though  shifting  less  than  they,  just  as  the 
trunk  of  a  tree  moves  less  than  the  branches.  Each 
phase  of  a  multiple  personality  has  its  own  character, 
and  these  phases  reappear  as  quasi  normal  moods.  The 
severe  test  of  illness  sometimes  develops  forms  of  charac- 
ter that  otherwise  might  have  remained  undeveloped. 
Within  the  orbit  of  the  invalid,  which  includes  the  doctor 
and  the  nurse,  selfishness  sometimes  reigns  and  narrow 
egotism,  together  with  sentimentality,  ignorance,  and 
weakness  of  the  will,  and  these  tendencies  may  remain 
active  long  enough  to  make  themselves  felt  through  modi- 
fications of  the  character.  But, —  what  is  more  impor- 
tant for  our  purposes, —  unselfishness,  devotion,  willing 
sacrifice  of  ambitions  and  desires,  thoughtfulness,  per- 
sistent effort,  loyalty,  the  sense  of  service,  may  likewise 
be  manifested  here,  in  their  best  form.  The  invalid  may 
make  excursions  into  certain  realms  which  are  rarely 
open  to  the  well  and  strong. 

^  There  are  forms  of  character  in  which  patience  is 
unified  with  clear  intelligence  and  strong  will,  with  in- 
stincts which  have  found  natural  expression  and  ideals 
which  have  grown  broader  with  experience.  The  pos- 
sessor of  such  a  character  as  this  has  at  his  command  a 


176  PSYCHOTHERAPEUTICS 

means  of  combating  illness,  a  compensation  for  illness, 
and  a  safeguard  against  certain  forms  of  illness,  which 
are  of  inestimable  value.  These  aids  are  needed,  for  the 
tests  to  which  the  invalid  is  exposed  are  serious  tests. 
Pain,  disappointment,  the  necessity  of  sacrificing  cher- 
ished hopes ;  the  necessity  of  ceaseless  struggles  with  the 
sense  of  weakness,  of  exhaustion,  of  isolaiien;  the  neces- 
sity of  living  in  almost  perpetual  companionship  with 
some  parasite  or  demon  or  phantom  of  the  fancy,  hardly 
less  hard  to  bear  for  being  recognized  as  fictitious; 
harder  still,  the  tearing  asunder  of  strong  ties  of  family 
and  friendship;  trials  such  as  these  may  mar,  but  often 
make  a  fine  character,  and  many  examples  of  the  latter 
result  are  known  to  all.  Such  persons  are  "  unified  "  to 
a  remarkable  degree.  The  syntheses  that  represent  each 
one,  even  of  their  more  trivial  acts  are  enriched  and  ani- 
mated by  similar  memories  and  motives.  The  emotional 
"  core  "  of  each  harmonizes  readily  with  all  the  rest. 

^  ^  But,  it  might  be  urged,  to  what  purpose  cite  the  ex- 
amples of  eminent  heroes  of  invalidism  if  it  is  an  impos- 
sible task  for  most  of  us  to  follow  where  they  have  led.^^ 
If  our  characters  depend  so  much  on  our  inherited  traits 
and  on  instincts  arising  at  the  very  threshold  of  infancy 
that  our  very  carriage  and  gestures,  our  voices,  and  the 
expressions  of  our  faces  reveal  our  natures  and  stamp  us 
to  the  casual  observer  for  what  we  are,  why  should  we 
fret  ourselves  with  vain  attempts  at  change.?     We  can- 

}  not  change  our  bodies,  how,  then,  can  we  hope  to  alter 
our  characters,  some  elements  of  which  are  almost  as 
fixed  as  our  spinal  reflexes  themselves.?  The  most  trivial 
habits,  even  if  recently  acquired,  obstinately  resist  dis- 
missal, and  the  same  is  still  more  true  of  our  obsessions. 
>The  causes  of  many  of  our  abnormal  traits  lie  out  of 
reach,  it  is  said,  buried  in  the  form  of  bodily  mechan- 
isms and  forgotten  experiences  of  the  past.     Timidity, 


CHARACTER  FORMATION  177 

vanity,  selfishness,  may  be  graven  so  deeply  into  our  lives 
that  although  we  can  conceal  them  for  a  certain  period 
it  is  often  claimed  that  we  cannot  eradicate  them  alto- 
gether. 

So  strongly  do  many  persons  feel  that  a  man's  charac- 
ter is  in  many  ways  outside  of  his  control,  that  the  very 
knowledge  that  he  belongs  to  a  certain  family,  even  to  a 
certain  race,  is  enough  to  make  them  doubt  his  capacity 
for  any  considerable  change.  Various  students  of  hered- 
ity rate  the  influence  of  education  very  low  *  as  compared 
with  that  of  hereditary  tendencies.  Even  admitting  that 
a  real  changing  of  the  character  is  possible,  the  invalid 
—  many  men  would  say  —  is  heavily  handicapped  for 
such  a  struggle.  His  inheritance  may  be  dark,  his  in- 
terests narrow,  his  opportunities  for  mingling  actively 
in  the  stimulating  game  of  life  and  feeling  the  warm 
breath  of  others'  zeal  are  relatively  few.  He  must  often 
stand  by  and  "  look  on  with  cold  hands  while  they  join 
in  the  whirling  game."  He  is  tempted,  pushed  and 
drawn  towards  a  life  of  selfishness,  discouragement,  and 
inertness.  But,  fortunately,  there  is  another  and  very 
different  side  to  this  picture,  and  one  which  both  science 
and  observation  contribute  the  materials  for  painting. 
The  argument  for  the  inalterability  of  the  fundamental 
tendencies  to  conduct  is  unsound;  the  motives  and  oppor- 
tunities present  to  the  invalid  are  inaccurately  stated. 
Character  is  to  be  measured  in  terms,  not  of  quantity, 
but  of  quality.  What  a  person  needs  in  order  to  fulfill 
his  destiny,  to  reach  his  goal,  whether  in  a  personal  sense 
or  with  reference  to  his  obligations  towards  the  world,  is 
a  power  of  insight  and  a  sense  of  progress  and  freedom, 
rather  than  any  special  form  of  external  accomplish- 
ment. There  are  many  kinds  of  insight  and  many  doors 
and  avenues  to  the  realms  of  freedom.     It  is  only  neces- 

iCf.     Heredity  in  Royalty.    Woods. 


178  PSYCHOTHERAPEUTICS 

sary  to  look  at  the  invalids  who  have  accepted  their 
conditions  cheerfully  and  taken  their  lot  at  its  best,  to 
realize  what  possibilities  are  open  to  those  who  can  es- 
cape from  estimating  the  pleasure  and  value  of  their 
lives  in  too  conventional  terms. 

We  see  daily,  to  be  sure,  persons  who  refuse  to  regard 
sickness  in  any  light  except  as  an  obstacle  and  a  misfor- 
tune of  a  wholly  different  class  from  those  of  a  more 
familiar  sort,  and  in  whom  it  excites  no  note  of  response 
other  than  that  of  terror  or  indignation.  Overwhelmed 
by  a  sense  of  isolation  and  of  personal  grievance,  they 
can  do  nothing  but  repine.  But  very  different  is  the  pic- 
ture presented  by  those  persons  whose  characters  are  so 
made  that  they  move  forward  in  spite  of  the  handicap 
of  illness,  so  steadily  that  like  a  stream  of  water  poured 
upon  the  ground,  which  finds  itself  met  by  one  obstacle 
after  another  only  to  turn  in  a  new  direction  and  pass 
on,  while  the  idea  of  being  conquered  or  permanently 
checked  seems  not  to  present  itself  before  their  minds. 
The  characters  of  such  persons  may  vary  greatly  in  de- 
tail, but  they  resemble  each  other  in  the  respect  that  they 
all  point  to  more  or  less  effectively  unified  personalities, 
to  a  fairly  concurrent  action  of  the  multifold  tendencies 
through  which  their  actions  are  determined. 

Even  faults,  failures,  and  defects  have  no  prescriptive 
right  to  bar  one's  way  to  a  larger  view  of  illness  or  of 
trouble,  and  should  not  be  allowed  to  do  so.  Morbid 
self-consciousness,  egotism,  the  tendency  to  follow  aims 
less  desirable  than  the  best,  unwelcome  as  they  are,  should 
nevertheless  be  actually  welcomed,  if,  as  so  often  hap- 
pens, they  mean  movement  and  progress.  The  outlook 
for  the  invalid  is  also  for  another  reason  much  better 
than  it  is  frequently  pictured.  The  dead  hand  of  an 
inheritance,  assumed  (usually  on  very  insufficient 
grounds)  to  be  "morbid,"  of  habits  supposed  to  be  un- 


CHARACTER  FORMATION  179 

alterably  fixed,  often  owes  its  baleful  power  to  the  fact 
that  its  workings  are  concealed  from  us. 
>  It  is  the  skeleton  in  the  closet,  the  tug  of  an  evil 
spirit  residing  in  the  mysterious  depths  of  our  subcon- 
scious life,  the  misunderstood  twists  and  tendencies  de- 
rived from  unfortunate  experiences  in  childhood,  experi- 
ences which  at  the  time  may  have  seemed  innocent  and 
trivial  enough  —  that  contribute  many  of  the  specters 
which  terrify  us  and  seem  to  block  our  paths.  It  is 
among  the  best  contributions  of  modern  psychiatry  and 
psychotherapy  that  it  has  been  shown  to  be  possible,  in 
a  remarkable  degree,  to  reverse  these  hidden  influences, 
which  are  due  to  old  environments,  to  misinterpreted 
emotions, —  in  brief,  to  ignorance.  The  discovery  that 
even  patients  with  dementia  precox  can  be  measurably, 
helped  through  application  of  this  principle  is  one  of  the 
encouraging  developments  of  modern  medicine. 

The  invalid  who  finds  himself  in  face  of  difficulties 
which  seem  so  hard  to  overcome  is  drawn  forward  and 
held  back  by  strong  and  varied  groups  of  impulses  in 
which  good  and  evil,  basal  instincts  and  fresh  ideals, 
traditions  of  courage  and  traditions  of  cowardice,  confi- 
dence, and  terror,  love  of  his  fellowmen  and  fear  of  his 
fcllowmen,  freedom  and  prejudice,  seem  to  be  joined  in 
combat  for  the  formation  of  his  character.  The  phy- 
sician's duty  is  to  aid  him  in  discovering  his  best  birth- 
right, in  helping  his  best  instincts,  the  best  fruits  of  his 
intelligence,  the  best  conquests  of  his  will,  to  gain  the 
mastery. 

The  habits  that  we  seek  to  alter,  after  all,  are  habits 
only.  They  reside  in  the  physiological  mechanism  of 
our  bodies,  and  these,  just  because  they  live,  are  more 
or  less  susceptible  of  change.  I  recall  an  interesting  con- 
versation with  an  able  student  of  these  subjects  with 
relation  to  the  bodily  signs  of  neurasthenic  states,  and 


180  PSYCHOTHERAPEUTICS 

remember  well  his  agreement  with  my  view  that' many  of 
them,  deep-seated  though  they  seem  to  be,  are  susceptible 
of  modification  in  the  direction  of  more  normal  nutritive 
development^  provided  only  that  their  mental  accompani- 
ments can  be  improved.  The  bare  fact,  indeed,  that  the 
nutrition  of  the  body  can  be  modified,  even  in  its  most 
intimate  forms,  through  the  action  of  mental  states,  is 
too  well  acknowledged  to  need  further  emphasis. 
^  Every  one  has  seen  individuals  whose  characters  have 
been  so  changed  through  development  that  for  all  prac- 
tical purposes  they  have  become  fundamentally  different 
from  what  they  had  been  before.  In  many  of  these  cases 
the  influence  of  illness  has  been  one  means  through  which 
this  change  was  brought  about.  The  mode  in  which  the 
change  takes  place  seems  usually  to  be  one  of  either  of 
^  two  sorts.  First,  the  former  traits  of  character  are, 
as  it  were,  side-tracked  by  the  formation  of  new  habits, 
a  new  personality,  dependent  on  new  interests  and  devel- 
'^oped  in  practical  substitution  for  the  old.  Next,  the 
new  character  may  absorb  the  old ;  as  when  a  person 
utilizes,  more  or  less  consciously,  all  the  influences,  pain- 
ful as  well  as  pleasurable,  which  have  been  brought  to 
bear  upon  him,  and  makes  his  faults  as  well  as  his  virtues, 
his  weakness  as  well  as  his  strength,  materials  for  the 
formation  of  a  new  character  which  without  these  influ- 
ences could  not  have  been  formed.  Intensely  self-con- 
scious persons  of  the  type  of  Bunyan  are  among  those 
who  adopt  this  latter  plan,  and  there  are  various  other 
types  of  invalids  whose  development  follows  similar  lines. 
Whichever  of  these  two  modes  of  effecting  a  change 
in  the  fundamental  movements  of  one's  life  is  chosen, 
three  great  influences,  sanctioned  alike  by  the  experience 
of  educators  and  the  observation  of  physicians  who  have 
dealt  with  morbid  minds,  must  be  mainly  relied  upon  in 
the  accomplishment  of  the  task,  y  These  are,  on  the  one 


CHARACTER  FORMATION  181 

hand,  the  utilization  of  emotions,  desires,  strong  inter-*- 
ests,  enthusiasm,  even  the  enthusiasm  attending  intellec- 
tual convictions  of  a  high  order;  on  the  other  hand,  per-4^ 
sistent,  arduous,  and  thorough  training,  carried  out  un- 
der a  clear  conception  of  the  difficulties  in  the  way;  and, 
finally,   the   eradicating   of   hidden   obstacles   to   success  ^ 
residing  in  the  form  of  motor  habits  and  memories  not 
clearly   present   before   the   waking   consciousness.     The 
principles  underlying  these  three  methods  need  to  be  sep- 
arately considered.  '^ 

To  speak,  first,  of  the  "  side-tracking  "  plan,  it  is  ob- 
vious that  if  the  invalid  is  to  be  led  to  adopt  new  inter- 
ests, to  gain  new  enthusiasms  of  sufficient  strength  and 
enduring  power  to  modify  his  character,  these  interests 
and  enthusiasms  must  be  in  harmony  with  his  own  nature ; 
he  cannot  be  expected  to  form  a  wholly  artificial  self. 
And  yet  by  assumption  he  is  cut  off  from  many  of  the 
special  interests  and  pleasures  prominent  in  other  per- 
sons' lives  and  perhaps  previously  in  his  own.  If  success 
is  to  be  obtained  it  must  be  because  every  person's  nature 
is  in  reality  far  broader  than  at  first  appears.  There 
are  persons  who  appear  able, —  not  merely  as  a  matter 
of  hypocritical  pretense,  but  actually  —  to  feel  their  in- 
terests merged  in  the  interests  of  the  community,  taken 
in  a  larger  or  a  narrower  sense.  Parents  usually  care 
intensely  for  the  happiness  of  their  children,  and  do  not 
feel  aggrieved  and  depressed  if  they  are  obliged  to  sac- 
rifice lesser  personal  interests  for  interests  of  this  greater 
sort.  Citizens,  and  even  races,  in  whom  the  sentiment 
of  patriotism  has  been  strongly  developed,  work  and  die, 
cheerfully  and  loyally,  for  national  successes  that  they 
will  never  see.  These  community  sentiments,  which  are 
thus  so  strong,  may  take  a  definitely  personal  or  a  rela- 
tively impersonal  form.  If,  now,  some  persons  are  so 
powerfully  moved  by  these  feelings,  it  must  be  that  all 


182  PSYCHOTHERAPEUTICS 

persons  are  capable  of  responding  to  them,  and  that  the 
physician's  problem  is  to  find  means  of  rousing  these  sen- 
timents into  flame.  I  believe  that  the  diflSculty  in  the 
way  of  this  result  consists  less  in  overcoming  an  essential 
resistance  than  in  overcoming  conventional  habits  of 
thought  and  feeling. 

The  fear  of  others'  criticisms  makes  us  cold.  Our 
conventional  views  of  success,  misfortune,  death,  are  too 
often  irrational  and  even  positively  low,  and  it  is  custom 
more  than  nature  that  makes  them  so.     The  very  fact 

>>  that  the  habit  of  esteeming  the  community  success  or  the 
success  of  a  cause  as  preferable  to  personal  success  may 
become,  within  certain  limits,  a  national  habit,  is  a  sort 
of  warrant  for  the  possibility  of  exciting  it  in  a  given 
case.  Invalids  should  learn  to  regard  themselves  as  mem- 
bers of  an  imaginary  band  of  persons,  inspired  by  loy- 
alty to  sentiments  of  health  and  courage,  although,  like 
themselves,  obliged  to  carry  burdens  of  a  certain  sort. 
The  numerous  individuals  who  suffer  from  ideas  of 
morbid  self-consciousness  carry  about  with  them  a  band 
of  imaginary  critics  and  enemies,  and  can  often  substi- 
tute for  them  without  great  difficulty  this  ideal  band  of 

;?»  allies.  It  is  a  question  of  gaining  new  ideals  of  living 
and  making  these  ideals  actually  count  as  standards. 
"  I  have  tried  to  live  so  that  my  smallest  act  would  cor- 
respond to  my  highest  ideal,"  wrote  an  intelligent  pa- 
tient with  whom  this  sentiment  had  become  the  prevailing 
motive  of  her  thoughts  and  conduct. 

Every  invalid  has  also  many  capacities  for  genuine 
interest  and  pleasure  of  the  lighter  sorts,  which  are 
capable  of  exciting  enthusiasm  if  only  they  are  followed 
without   the   reserve   induced   by   conventional   restraints 

/"  and  by  the  habit  of  comparison  of  one's  self  with  others. 

^In  the  way  of  this  result  stands  the  instinctive  longing 

for  individual   success,  misunderstood   and  taken  in   an 


CHARACTER  FORMATION  183 

exclusive  and  personal  sense,  as  if  one  man's  success  must 
mean  another's  failure.  Personal  courage  and  personal 
energy  and  enterprise  do  indeed  seem  to  stand  at  the 
very  center  of  all  progress,  but  they  connote  much  that 
is  barbarous  and  need  the  counter-balancing  note  of  the 
"  courage  to  let  the  courage  sink."  ^  We  continually 
underrate  or  wholly  fail  to  recognize  the  deeper  motives 
by  which  we  might  be  impelled.  We  like  too  well  to  im- 
agine that  our  lives  and  impulses  are  clear  before  us, 
and  to  gain  this  seeming  clearness  we  close  our  eyes  to 
great  masses  of  influences  which  it  would  cost  us  much 
pains  and  perhaps  pain  to  analyze. 

^  It  is  obvious  from  what  has  been  said  that  character 
serves  as  a  stimulus  to  action.  It  is  likewise  known  that 
through  experimental  methods,  as  in  the  case  of  a  hyp- 
notized patient,  it  is  possible  to  secure  impulses  to  action 
which,  primarily  at  least,  do  not  deserve  the  name  of 
character  or  even  of  emotional  interest.  In  other  words, 
it  has  been  found  that  any  positive  suggestion  made 
when  the  mind  is  in  a  receptive  state  is  likely  to  be  car- 
ried into  execution.  In  fact,  the  attempt  has  been  made 
to  form  character  through  "  suggestion,"  especially 
with  children,  and  it  is  indeed  possible  that  cettain  steps 
in  this  progress  can  be  thus  accomplished.  It  is,  how-< 
ever,  instructive  to  note  that  there  is  a  striking  differ- 
ence between  the  impulses  to  action  formed  through  sug- 
gestion and  those  gained  through  experience  and  strug- 
gle, even  though  the  apparent  result  and  form  of  the 
action  might  seem,  now  and  then,  to  be  the  same  in  the 
two  cases.  This  difference  resides  in  the  fact  that  al- 
though an  impulse  to  action  secured  through  suggestion 
may  fit  us  to  carry  out  a  certain  result,  and  thus  make 
us  adapted  for  a  definite  environment,  the  position  of 
character  —  assuming,  of  course,  that  it  is  character  of 
2  Arthur  H.  Clough. 


184  PSYCHOTHERAPEUTICS 

a  desirable  sort  —  adapts  us  for  environments  of  many 
sorts.  The  memories  of  the  experiences  through  which 
a  person  has  passed,  under  these  circumstances,  come 
to  his  aid  in  the  way  of  enriching  his  perceptions  and  his 
thoughts,  to  an  extent  which  it  would  be  otherwise  im- 

y  possible. 

^The  second  of  the  two  methods  of  character  modifica- 
tion consists  in  the  systematic  study  of  one's  personal 
experiences  and  traits  in  the  interest  of  an  outcome  bet- 
ter than  the  present.  Much  has  been  said  of  the  evils 
of  introspection,  and  this  would  seem  to  imply  introspec- 
tion on  a  large  scale.     But  there  are  two  sorts  of  intro- 

^spection.  One  of  them  is  simply  emotional,  morbid,  and 
depressing,  and  ends  in  nothing  that  is  useful,  while  the 
other  is  a  thoughtful  study  of  one's  self,  made  desirable 
either  for  the  sake  of  increasing  the  general  sum  of 
knowledge,  or  for  the  sake  of  the  correction  of  tenden- 
cies which  absolutely  need  correction.  This  self -Investi- 
gation, which  is  much  better  conducted  with  the  aid  of 
the  skilled  physician,  may  take  either  one  of  two  forms. 
The  patient  may  scrutinize  the  obstacles  consisting  in  his 
own  peculiarities  of  disposition  and  of  habits,  and  learn 
to  estimate  them  at  their  true  value,  regarding  them,  so 
far  as  practicable,  in  a  matter  of  fact  way  and  without 
undue  emotion,  especially  without  self-reproach,  and  may 
utilize  the  information  that  he  gains  in  the  interests  of 
progress.  Or,  he  may  make  a  very  thorough  scrutiny 
of  the  origin  of  his  symptoms,  be  they  what  they  may, — 
morbid  self-consciousness,  fears,  undesirable  feelings  to- 
ward those  around  him,  dissociations  of  the  hysterical 
type.  Every  thoughtful  person  is  aware  that  many  of 
these  symptoms  have  their  roots  in  experiences  and  hab- 
its formed  in  childhood,  but  there  are  few  persons,  even 
though  thoughtful,  who  have  as  yet  learned  to  appreci- 
ate the  full  bearing  of  this  principle.     Mental  conflicts 


I  CHARACTER  FORMATION  186 

may  begin  almost  in  the  cradle,  and  are  often  attended 
or  soon  followed  by  desires,  aspirations,  and  fears,  which 
too  often  are  given  no  outlet,  but  are  ostensibly  sup- 
pressed. In  reality  this  suppression  means  frequently 
conversion  into  some  other  form  and  the  establishment 
of  an  undesirable  tendency  to  morbid  growth.  The 
chapter  by  Dr.  Ernest  Jones  describes  this  principle  with 
far  better  justice  than  I  can  render  it  in  these  few  lines. 
I  will  only  say  that  the  longer  I  have  studied  the  matters 
of  which  his  chapter  treats,  the  more  fully  I  am  con- 
vinced of  their  significance.  I  have  already  discussed 
them  somewhat  in  the  earlier  portion  of  this  chapter. 

Besides  these  two  great  methods  of  character  forma- 
tion, that  which  operates  through  the  operation  of  new 
interests  and  that  which  operates  through  the  scrutiny 
of  past  experiences  and  present  peculiarities, —  there  is 
a  large  field  for  efforts  toward  character-formation 
^  through  the  systematic  training  of  the  will  and  the  as- 
sumption of  duties  and  obligations  toward  individuals 
and  the  community. ' 

Back  of  them  all,  however,  lie  the  question  and  the 
doubt,  "  Do  we  mean  to  substantiate  our  principles  with 
acts".?  "Are  we  prepared  to  pay  the  price,  in  labor, 
of  freedom  and  self-control .?  "  If  these  questions  can 
be  honestly  answered  in  the  affirmative,  the  battle  is 
half  won.  For  the  development  of  character  in  harmony 
with  new  ideals  and  needs  it  is  not  necessary  or  desirable 
to  eradicate  the  past,  but  only  to  make  it  lend  some  ele- 
ment of  value  to  the  present.  The  oriental  philosophy 
would  see  virtue  reached  through  the  obliteration  not 
only  of  sensuality  but  of  the  senses.  A  typical  reductio 
ad  ahsurdum  of  this  principle  is  furnished  by  the  con- 
duct of  those  devotees  who  have  themselves  immured  in 
narrow  cells  to  be  thereafter  kept  alive  for  varying  pe- 
riods through  food  thrust  in  by  narrow  apertures. 


186  PSYCHOTHERAPEUTICS 

The  Western  philosophy  adopts  sense  pleasures  as  ele- 
ments to  be  utilized;  adopts  the  seeming  paradox  that 
sins  and  pains,  even  if  apparently  useless,  are  not  incom- 
patible with  the  theory  of  a  moral  universe.  The  man^ 
of  finest  character  has  long  ceased  to  be  sensual;  yet  he 
does  not,  for  that,  shut  his  eyes  upon  his  natural  in- 
stincts, but  remains  sense  free  and  sense  active,  and  rec-  I 
ognizes  the  splendid  working  out  of  sense  instincts  in 
civilization  and  community  life.  Neither  do  the  tempta- 
tions and  trials  of  illness  and  misfortune  fetter  his 
thought  any  more  than  the  temptations  of  sensuality. 

The  development  of  character  in  a  desired  direction  is 
then  to  be  secured  through  free  choice,  but,  as  a  rule,u. 
slowly,  perhaps  painfully,  and  under  constant  vigilance  ^^ 
and  effort.^     Most  of  all,  the  principle  should  be  recog'i_ 
nized  that  in  the  conscious  attempt  to  modify  character 
and  to  escape  from  the  bondage  of  hampering  habits, 
what  we  really  seek  is  not  the  destruction  of  order,  in 
the  supposed  interests  of  freedom,  but  acceptance  of  aw, 
more  comprehensive  order  as  the  highest  choice  of  free-<- 
dom.     It  is  the  conception,  under  the  form  of  an  ideal 
vision,   of   this  higher   order,   combined  with   the  power 
which  the  vision  furnishes  of  seeing  one's  self  as  part  of 
a  larger  whole,  one  member  of  a  great  company  of  per- 
sons not  wholly  describable  in  terms  of  bodily  forms,  a 
company   whose   pleasures   and   progress   each   one   may 
enjoy,  regardless  of  his  individual  lot;  it  is  this  concep- 
tion that  makes  illness  not  only  bearable,  but  sometimes 
the  road  to  a  more  satisfactory  sort  of  health. 

3  It  is  interesting  to  note  that  Dante,  in  his  Purgatorio,  while 
asserting  the  possibility  of  progress,  symbolizes,  by  the  lengths  of 
time  which  he  assumes  to  be  required  for  his  modifications  of  char- 
acter, the  practical  difficulty  in  the  way  of  the  result. 


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